a nurse is providing care to a child with a diagnosis of bronchiolitis what is the priority nursing intervention
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Nursing Elites

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Pediatric HESI Test Bank

1. When caring for a child diagnosed with bronchiolitis, what is the priority nursing intervention?

Correct answer: B

Rationale: The priority nursing intervention for a child with bronchiolitis is providing respiratory therapy. This intervention aims to maintain airway patency, optimize oxygenation, and support effective breathing. Administering bronchodilators, though important, may not be the initial priority as respiratory therapy takes precedence in ensuring adequate oxygenation and ventilation. Monitoring oxygen saturation is crucial but is usually part of the ongoing assessment following the initiation of respiratory therapy. Encouraging fluid intake is essential for hydration but is not the priority intervention when addressing the respiratory distress associated with bronchiolitis.

2. Which of the following signs or symptoms is more common in children than adults following head trauma?

Correct answer: A

Rationale: Nausea and vomiting are more common in children following head trauma due to their higher risk of increased intracranial pressure. Children have less space for swelling within the skull compared to adults, making them more prone to experiencing symptoms like nausea and vomiting. Altered mental status and changes in pupillary reaction can also occur in both children and adults following head trauma, but they are not specifically more common in children. Tachycardia and diaphoresis are generally signs of autonomic nervous system activation and may occur in both children and adults, but they are not typically more common in children compared to adults following head trauma.

3. A 4-year-old child is brought to the emergency department with a suspected fracture. What is the priority nursing action?

Correct answer: A

Rationale: The priority nursing action when a child with a suspected fracture is brought to the emergency department is to immobilize the affected limb. Immobilization helps prevent further injury until a fracture is confirmed or ruled out. Applying ice or elevating the limb can wait until after immobilization has been achieved. Checking the child's neurovascular status is important but is not the priority action in this situation.

4. A healthcare professional is educating a parent group about the importance of immunizations. Which disease can be prevented by the varicella vaccine?

Correct answer: D

Rationale: The varicella vaccine is specifically designed to prevent chickenpox. Measles, mumps, and rubella are prevented by different vaccines (MMR vaccine for measles, mumps, and rubella). Therefore, the correct answer is chickenpox (varicella). It is crucial for healthcare professionals to provide accurate information about vaccines to help ensure the health and well-being of individuals.

5. When assessing a child with suspected bacterial meningitis, what clinical manifestation is the nurse likely to observe?

Correct answer: B

Rationale: The correct answer is B: High fever. In bacterial meningitis, a high fever is a common clinical manifestation due to the body's inflammatory response to the infection. While photophobia (choice A) is also a common symptom in meningitis, it is not as specific as a high fever. Rash (choice C) is more commonly associated with viral infections or other conditions, rather than bacterial meningitis. Nasal congestion (choice D) is not a typical clinical manifestation of bacterial meningitis and is more commonly seen in respiratory infections. Therefore, when assessing a child with suspected bacterial meningitis, the nurse is most likely to observe a high fever as a key clinical manifestation.

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