The telephone triage nurse receives a call from a parent who states that her 18-month-old is making a crowing sound when he breathes and is hard to wake up. Which is the nurse's priority action?
1. Advise the parent to hang up and call 911.
2. Reassure the parent and provide instructions on home care for the child.
3. Instruct the parent to make an appointment for the child to see the health care provider.
4. Obtain the history of the illness from the parent.
1
Rationale 1: The nurse should immediately recognize the symptoms of severe upper respiratory distress and advise the parent to call 911. Crowing is heard when there is severe narrowing of the airway.
Rationale 2: Home care is not appropriate, as a crowing sound at rest with a change in the level of consciousness makes this an emergency situation; the nurse should instruct the parent to call 911.
Rationale 3: Making an appointment would be appropriate in non-emergency situations.
Rationale 4: Obtaining the history is appropriate only after the child has received emergency treatment to control the airway.
Global Rationale:
You might also like to view...
What is most appropriate for a nurse to include when preparing discharge plans for a patient with SLE?
a. Need to consume 2 L of fluid daily b. Close monitoring of daily blood glucose level c. Use of daily sunscreens with a sun protec-tion factor (SPF) higher than 15 d. Careful concern for certain food allergies
You are the circulating nurse for several surgeries today. What would be one of your major goals for each of these patients?
A) Latex-allergy symptoms treated rapidly B) Surgery unsuccessful C) Maintenance of the patient's dignity D) Complications treated rapidly
A family struggles with clear communication, and members of the family often seek the help of other systems for personal validation and gratification. What would be an appropriate nursing diagnosis for this family?
1. Altered Family Processes related to communication patterns 2. Impaired Verbal Communication related to inability to communicate 3. Ineffective Family Coping evidenced by assistance from outside sources 4. Knowledge Deficiency (communication patterns) related to dysfunctional patterns of communication
A student nurse is concerned because a patient is weak after abdominal surgery. Which of the following should she do to ensure that one of the eight preventable conditions identified by the Center for Medicare and Medicaid does not occur?
A. Use the "rights" of medication administration. B. Provide frequent opportunities to use the bathroom. C. Complete thorough documentation. D. Complete discharge teaching as quickly as possible.