a 6 year old child with asthma is admitted to the hospital with an acute exacerbation what is the priority nursing intervention
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Nursing Elites

HESI LPN

Pediatric HESI 2024

1. A 6-year-old child with asthma is admitted to the hospital with an acute exacerbation. What is the priority nursing intervention?

Correct answer: A

Rationale: Administering a bronchodilator is the priority intervention for a child experiencing an acute asthma exacerbation. Bronchodilators help to dilate the airways, making breathing easier and relieving acute symptoms of asthma. Antihistamines are not the first-line treatment for asthma exacerbations; they are more commonly used for allergic reactions. Corticosteroids are beneficial in reducing inflammation in asthma but are usually administered after bronchodilators to provide long-term control. Oxygen therapy may be necessary in severe cases of asthma exacerbation, but bronchodilators take precedence in improving airway patency and respiratory distress.

2. The parents of a 6-month-old infant are concerned about the risk of sudden infant death syndrome (SIDS). What should the nurse recommend to reduce the risk?

Correct answer: A

Rationale: The correct recommendation to reduce the risk of SIDS in infants is to place them on their back to sleep. This sleeping position helps prevent the occurrence of SIDS by maintaining an open airway and reducing the risk of suffocation. Using a pacifier during sleep has also shown some protective effect against SIDS, but it is not as effective as placing the infant on their back. Having the infant sleep on their side is not recommended as it can increase the risk of accidental suffocation. Keeping the infant's room cool does not directly reduce the risk of SIDS.

3. The nurse is implementing care for a school-age child admitted to the pediatric intensive care unit with diabetic ketoacidosis (DKA). Which prescribed intervention should the nurse implement first?

Correct answer: A

Rationale: The correct first intervention when managing a child with diabetic ketoacidosis is to begin intravenous saline solution to address dehydration and restore electrolyte balance. Rehydration is essential to improve perfusion and correct electrolyte imbalances. Administering insulin without addressing dehydration can potentially lead to further complications. Placing the child on a cardiac monitor or pulse oximetry monitor is important but not the initial priority in managing DKA.

4. After surgery to correct hypertrophic pyloric stenosis (HPS) in a 3-week-old infant who had been formula-fed, which postoperative feeding order is appropriate?

Correct answer: C

Rationale: Following surgery for hypertrophic pyloric stenosis (HPS) in infants, it is appropriate to resume regular formula feeding within 24 hours postoperatively to support recovery. This helps maintain adequate nutrition and hydration for the infant. Choice A is incorrect because thickened formula may not be necessary and could potentially cause issues postoperatively. Choice B is incorrect as withholding feedings for the first 24 hours can lead to nutritional deficiencies and delay recovery. Choice D is inappropriate as additional glucose feedings are not typically indicated postoperatively for infants with HPS and may not provide the necessary nutrition needed for recovery.

5. A child is being assessed for suspected intussusception. What clinical manifestation is the nurse likely to observe?

Correct answer: C

Rationale: The correct clinical manifestation that a nurse is likely to observe in a child with suspected intussusception is abdominal distension. Intussusception is a medical emergency where a part of the intestine folds into itself, causing obstruction. Abdominal distension is a common symptom due to the obstruction and the build-up of gases and fluids. While currant jelly stools (Choice B) are a classic sign of intussusception, they are typically seen in later stages of the condition and may not be present during the initial assessment. Projectile vomiting (Choice A) is more commonly associated with conditions like pyloric stenosis. Constipation (Choice D) is not a typical manifestation of intussusception; the condition usually presents with severe colicky abdominal pain and possible passage of blood and mucus in stools.

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