0535: The parents of a 4-year-old report that their child has not been feeling well for the past two days. They went to urgent care, and the child was diagnosed with pharyngitis. Less than an hour ago, the parents were abruptly awakened by their child drooling and reporting throat pain. On assessment, the child is restless and agitated. The child responds with a muffled voice. Sternal retractions are noted, and lung sounds are clear in the upper fields and diminished bilaterally in the bases. Radial pulse 2+ and thready. Vital signs: T 100.4 °F (38°C), P 125, RR 40, BP 109/74, pulse oximetry 95% on room air.
➢ Complete the following sentences by choosing from the lists of options.
The nurse should ****initially**** [place resuscitation equipment near the child. / start a peripheral vascular access device. / obtain an order for blood and throat cultures. / assess the child's current vaccination status.] br When performing an assessment, the nurse should avoid [using a pen light to inspect the client's throat. / using a tongue depressor to inspect the client's throat. / inspecting the client's throat with a flashlight. / palpation of the client's cervical lymph nodes.] br It is a ****priority**** for the nurse to obtain a prescription for [acetaminophen. / ketorolac. / ceftriaxone. / levalbuterol via nebulizer.] br The nurse should [keep the child's head of the bed positioned at 15-30 degrees. / accompany the child to the radiology department. / anticipate that the child will require overnight observation in the medical-surgical unit. / request an order for a nasogastric tube (NGT) to assist the client with rehydration.]
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