Difficulty: Medium
Average Score: 80%
Simulated
Passage / Scenario
Nurses Notes: 0915: Received the child awake, alert, and crying. Parent states that child was playing with remote control toy and when the parent the child crying, they noticed that a battery was missing from the toy. The parent states that the child was drooling more and witnessed them gagging periodically. 0930: Child is lying on parent's chest with eyes open and requesting ├óÔé¼╦£sippy cup.' Continues to have expiratory wheezing in bilateral upper lobes. Preparing child for diagnostic testing. Vital Signs: Blood pressure 88/45 mm Hg, Heart rate 90/min, Respiratory rate 30/min, Axillary temperature 36.9├é┬░C (98.4 F), Oxygen saturation 96%. 0930: Blood pressure 86/46 mmHg, Heart rate 88/min, Respiratory rate 28/min, Axillary temperature 36.9 C(98.4 F), Oxygen saturation 95%. Assessment: 0915: Child awake and sobbing, asking for ├óÔé¼╦£sippy cup' with excessive drooling and occasionally gagging. Breath sounds with small expiratory wheezing noted in bilateral upper lobes, respirations slightly elevated as child continues to cry and sob. Oxygen saturation 96% on room air. Penlight used to inspect the throat with no visual signs of foreign object in child's nose or ears upon inspection. Pupils equal, round, and reactive to light and accommodation. Abdomen soft and non-tender with active bowel sounds in all four quadrants. Skin warm, pink, and smooth. Yellow urine noted in child's diaper. Provider notified of assessment findings. Laboratory Results: 0930: x-ray of the neck, chest, and abdomen completed plane radiographic study identifies object in esophagus, No foreign objects visualized in the chest or abdomenComplete the following sentence by using the list of options. The nurse should first ___ followed by ___.
Correct answer
A, E
Rationale
First, the nurse should keep the child NPO (nothing by mouth) to prevent aspiration during the endoscopy (E). This is crucial for safety. Next, preparing the child for flexible endoscopy (E) is important to ensure the procedure is conducted smoothly. Choices B, C, D, F are incorrect as they are not directly related to the immediate safety and preparation required for the endoscopy.