a 3 year old child has a sudden onset of respiratory distress the mother denies any recent illnesses or fever you should suspect a 3 year old child has a sudden onset of respiratory distress the mother denies any recent illnesses or fever you should suspect
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Nursing Elites

ATI LPN

LPN Pediatrics

1. A 3-year-old child has a sudden onset of respiratory distress. The mother denies any recent illnesses or fever. You should suspect:

Correct answer: B

Rationale: In a 3-year-old child with a sudden onset of respiratory distress and no recent illnesses or fever, the likely cause is a foreign body airway obstruction. Foreign body obstruction can lead to sudden respiratory distress without other preceding symptoms. It is crucial to consider this possibility and act promptly to clear the airway in such cases to prevent serious complications.

2. A nurse is admitting a client who has meningococcal meningitis. What should the nurse do first?

Correct answer: A

Rationale: The first priority when admitting a client with meningococcal meningitis is to initiate droplet precautions. This is essential to prevent the transmission of the infection to others, as meningococcal meningitis is highly contagious through respiratory droplets. Starting intravenous antibiotics or performing a complete assessment can follow, but the immediate concern is to implement infection control measures. Notifying the healthcare provider should also be done but is not the first action to take in this situation.

3. A nurse is caring for a client receiving a dopamine infusion via a peripheral IV. Which of the following actions should the nurse take if the IV site appears infiltrated?

Correct answer: A

Rationale: Corrected Rationale: If infiltration is suspected, the nurse should immediately stop the dopamine infusion to prevent further damage to the surrounding tissue. Choice A is the correct answer because continuing the infusion can lead to tissue damage and compromise the client's care. Slowing the infusion (Choice B) is not sufficient to prevent harm and may still cause damage. Applying a warm compress (Choice C) or a cold compress (Choice D) is not the recommended action for infiltration; stopping the infusion is crucial to prevent complications.

4. To monitor clients registered in long-term regimens, such as Multi-Drug Therapy, which component will be most useful?

Correct answer: C

Rationale: The Target/Client List is a record that specifically tracks clients enrolled in MDT and includes essential data like the dates when clients collected their monthly drug supplies. This list is crucial for monitoring and managing clients in long-term regimens, providing a comprehensive overview of client participation and treatment progress.

5. The client will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. What action should the nurse take to assist the client?

Correct answer: B

Rationale: Providing the client with a device holder to wear around the waist allows them to comfortably carry the Holter monitor while engaging in normal activities throughout the 24-hour monitoring period. This approach supports the client's mobility and ensures the monitor is securely in place for accurate readings. Shaving the front of the client's chest is unnecessary and not a standard practice for Holter monitor placement. Instructing the client to rest as much as possible does not promote normal daily activities which are important for accurate monitoring. Covering the monitor in plastic wrap before bathing is not recommended as it may affect the functionality of the device.

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