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 take?
Prepare to assist with intubation.
Prepare a cool mist tent.
Suction the child's oropharynx.
Obtain a throat culture.
The Correct Answer is A
Choice A rationale:
Preparing to assist with intubation is the appropriate action for a nurse caring for a child with suspected epiglottitis. Epiglottitis is a medical emergency where the airway can become severely compromised due to inflammation of the epiglottis. Intubation ensures a secure airway, allowing the child to breathe and preventing respiratory distress.
Choice B rationale:
Preparing a cool mist tent is not the priority in suspected epiglottitis. While humidified air can provide comfort for respiratory distress, it does not address the potential for airway obstruction. Intubation takes precedence in this critical situation.
Choice C rationale:
Suctioning the child's oropharynx may worsen the condition in suspected epiglottitis. Suctioning can stimulate the epiglottis, triggering a spasm and further obstructing the airway. Intubation is the primary intervention to secure the airway safely.
Choice D rationale:
Obtaining a throat culture is not the immediate action in suspected epiglottitis. While a throat culture may confirm the diagnosis, the priority is securing the airway to prevent respiratory distress and hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Taking antibiotics when having a virus is not a correct understanding of infection prevention. Antibiotics are ineffective against viruses and should only be used for bacterial infections under the guidance of a healthcare provider. This statement indicates a misunderstanding of infection prevention.
Choice B rationale:
Washing hands for at least 20 seconds with soap and water is the recommended practice for infection prevention. Washing hands for 10 seconds may not be sufficient to remove all germs effectively. This statement does not demonstrate a proper understanding of hand hygiene.
Choice C rationale:
Cleaning a cat's litter box during pregnancy is not recommended due to the risk of contracting toxoplasmosis, a parasitic infection that can harm the fetus. Pregnant individuals should avoid handling cat litter to prevent exposure to this infection. This statement indicates a lack of awareness regarding infection prevention during pregnancy.
Choice D rationale:
Waiting 5 days after the chickenpox sores have crusted before visiting a person with chickenpox demonstrates an understanding of infection prevention. Chickenpox is highly contagious, and individuals should avoid close contact until the sores have fully healed and crusted over. This statement reflects appropriate knowledge about preventing the spread of contagious diseases during pregnancy.
Correct Answer is D
Explanation
Choice A rationale:
Asking about past coping mechanisms can provide valuable information, but in this situation, where the client is expressing thoughts of hopelessness, it's crucial to assess the immediate risk of suicide. Therefore, this choice is not the best option in this context.
Choice B rationale:
Involving significant others in the client's care is important, but it doesn't address the client's current emotional state and suicidal ideation. This choice does not take priority in this scenario.
Choice C rationale:
While exploring family history, including suicide, is relevant, it's not the first question to ask. Assessing the client's current thoughts and feelings should be the priority before delving into family history. Therefore, this choice is not the best option at this moment.
Choice D rationale:
(Correct Choice) This is the most appropriate question to ask first. Assessing the client's suicidal ideation is crucial for ensuring their safety. If the client expresses suicidal thoughts, the nurse can take immediate steps to keep the client safe, such as involving a mental health professional or initiating a suicide risk assessment.
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