A school nurse observes a child, with a peanut allergy, in obvious distress, wheezing and cyanotic, after ingestion of some trail mix containing peanuts. Place the interventions the nurse should implement in order of the highest priority to the lowest priority. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d).

Correct Answer: c

Rationale: The highest priority intervention in this situation is 'C': Promptly administer an intramuscular dose of epinephrine. Epinephrine is The first-line treatment for anaphylaxis, which is a severe allergic reaction that can be life-threatening. Administering Epinephrine as soon as possible can help reverse The symptoms and stabilize The child.

Correct Answer: C

Rationale: The most appropriate nursing intervention for the jittery and twitching newborn with a high-pitched cry is to obtain serum glucose and serum calcium levels (Option C). These symptoms are indicative of possible hypoglycemia or hypocalcemia, which are common issues for newborns. Monitoring glucose and calcium levels will help identify and address any imbalances that may be causing these symptoms. Administering glucose (Option D) may be necessary if hypoglycemia is confirmed, but it should be based on the results of blood tests. Monitoring blood pressure (Option A) and obtaining a urine sample to detect glycosuria (Option B) are not the priority interventions in this scenario compared to assessing serum glucose and calcium levels.

Correct Answer: D

Rationale: The screening test for PKU (Phenylketonuria) is most reliable when the blood sample is fresh and taken from the heel. This is because the test requires a small amount of blood, and obtaining a fresh sample from the heel minimizes the risk of contamination and ensures accurate results. Additionally, collecting the blood sample from the heel is less invasive for the newborn and is a common practice for newborn screening tests. Blood samples taken from cord blood, 14 days after birth, or before oral feedings are initiated may not provide accurate results for the PKU screening test.

Correct Answer: D

Rationale: Asking the child to draw a picture can be the most helpful technique in this situation because it allows the child to express themselves visually, especially when verbal communication may be challenging. Drawing can serve as a form of communication that the child may find more comfortable and engaging. It provides the child with a non-verbal way to express their thoughts, feelings, and experiences, which can help the nurse better understand the child's perspective and potentially build a connection with them. Additionally, examining the child's drawings can provide valuable insights into their emotional state and concerns, facilitating more effective care and support.

Correct Answer: B

Rationale: In grading pulses, the normal pulse is typically designated as +1. This indicates a pulse that is easily felt, normal in strength, and corresponds to a healthy pulse rate. A +1 pulse is considered regular, not too weak or too strong, and is indicative of good cardiovascular health. Any abnormalities in pulse strength or rate would be graded differently.