A charge nurse on a pediatric unit is observing a newly licensed nurse provide care for a child diagnosed with acute epiglottis. Which of the following actions by the newly licensed nurse indicates that the charge nurse should intervene?
Assessing vital signs with temperature and oxygen saturation.
Gathering necessary supplies for possible intubation.
Assessing the child's throat using a tongue blade.
Reporting an elevated white blood count to the health care provider.
The Correct Answer is C
A. Assessing vital signs, including temperature and oxygen saturation, is appropriate for monitoring the child's condition and identifying any signs of respiratory distress or infection.
B. Gathering necessary supplies for possible intubation is a proactive measure in case the child experiences airway obstruction. Acute epiglottitis can lead to rapid deterioration in the child's airway.
C. Assessing the child's throat using a tongue blade can trigger airway obstruction in a child with acute epiglottitis, which is a medical emergency. The throat should not be examined visually due to the risk of causing a spasm or obstruction.
D. Reporting an elevated white blood count is a normal part of managing acute infections, such as epiglottitis, and should be done to inform the healthcare provider of the patient's condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Tracheoesophageal fistula is a congenital anomaly that affects the esophagus and is not associated with abdominal masses or blood and mucus in the stool.
B. Hypertrophic pyloric stenosis typically causes projectile vomiting and failure to thrive, but it does not typically present with an abdominal mass or blood in the stool.
C. Intussusception occurs when part of the intestine telescopes into another part, causing a mass, abdominal pain, and sometimes blood and mucus in the stools, which is consistent with the signs described.
D. Inguinal hernia is a protrusion of abdominal contents into the groin area, not typically associated with abdominal masses in the upper quadrant or blood in the stool.
Correct Answer is C
Explanation
A. Educating the child's parents on hand hygiene is important but not specific to airborne precautions.
B. A surgical mask is not required for a child on airborne precautions unless the child is capable of wearing it.
C. Restricting contact to immune individuals helps prevent the spread of airborne infections, especially in vulnerable settings such as healthcare facilities.
D. Antibiotics should not be given prophylactically unless there is a specific bacterial infection, and airborne precautions are typically used for viral infections like tuberculosis or measles.
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