A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse include in the plan nurse take?
Prepare a cool mist tent.
Suction the child's oropharynx.
Prepare to assist with intubation.
Obtain a throat culture.
The Correct Answer is C
A. A cool mist tent may be helpful for other respiratory conditions but is not the priority in epiglottitis.
B. Suctioning the oropharynx can cause further airway irritation and increase the risk of airway obstruction.
C. Epiglottitis can rapidly lead to airway obstruction, and intubation may be necessary to secure the airway.
D. Obtaining a throat culture is contraindicated as it may trigger airway closure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential condition: Deep vein thrombosis
Based on the provided information, the client is most likely experiencing Deep Vein Thrombosis (DVT). This is suggested by the client's history of smoking, lack of exercise, obesity, recent surgery, and the fact that they are not wearing sequential compression devices due to discomfort.
Actions to Take
- Request a prescription for a lower-extremity Doppler flow study: This will help confirm the presence of a blood clot in the deep veins.
- Assess for Homan's sign: This is a clinical test used to check for DVT, although it's not always reliable.
Parameters to Monitor
- Signs of bleeding after anticoagulation initiation: This is crucial because anticoagulants are often used to treat DVT, and monitoring for bleeding is essential.
- PT/INR and platelet count: These parameters help assess the effectiveness and safety of anticoagulation therapy.
Correct Answer is B
Explanation
A. Identifying a sour taste tests cranial nerves VII (facial) and IX (glossopharyngeal).
B. Cranial nerve XI (the spinal accessory nerve) controls the muscles involved in shoulder shrugging and head turning.
C. Frowning symmetrically assesses the facial nerve (VII).
D. Sticking out the tongue assesses the hypoglossal nerve (XII).
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