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 B
Explanation
A. Read medication labels at least two times prior to administration: Labels should be read three times (when retrieving, preparing, and administering).
B. Avoid preparing medications for more than two clients at one time: Reduces the risk of medication errors by minimizing task-switching and confusion.
C. Inform clients about the action of each medication prior to administration: While educating clients is essential, it is not always required before every medication.
D. Complete an incident report if a client vomits after taking a medication: An incident report is typically required only for errors or adverse events.
Correct Answer is B
Explanation
A. Moderate variability in the FHR: Incorrect. Moderate variability (6-25 bpm) is a reassuring sign of fetal well-being.
B. Prolonged decelerations: Prolonged decelerations, defined as a decrease in fetal heart rate (FHR) of at least 15 beats per minute lasting 2 to 10 minutes, indicate potential fetal hypoxia or distress and require immediate notification of the provider.
C. Baseline FHR 115/min: Incorrect. A baseline FHR of 115/min is within the normal range of 110-160 bpm.
D. Three uterine contractions within 10 min: Incorrect. This contraction pattern is within the normal range for active labor (normal is 2-5 contractions in 10 minutes).
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