A nurse in an urgent care clinic is contributing to the plan of care for a child who has suspected epiglottitis. Which of the following interventions should the nurse plan to include?
Initiate contact precautions.
Monitor pulse oximetry.
Obtain a throat culture.
Administer epinephrine IM.
The Correct Answer is B
Choice A reason:
The nurse should not initiate contact precautions for a child with suspected epiglottitis. Epiglottitis is primarily caused by Haemophilus influenzae type B, and it spreads through respiratory droplets. Contact precautions are not necessary as the transmission occurs through droplets, and standard precautions should be sufficient.
Choice B reason:
The nurse should monitor pulse oximetry. Epiglottitis is a condition where the epiglottis becomes inflamed and swollen, potentially blocking the airway. Monitoring the child's pulse oximetry helps assess their oxygen saturation levels, which is crucial in determining if there is adequate oxygenation. If the oxygen saturation drops significantly, immediate intervention might be needed to maintain the child's airway and prevent hypoxia.
Choice C reason:
Obtaining a throat culture is not an appropriate intervention for suspected epiglottitis. In cases of suspected epiglottitis, the priority is to ensure the child's airway is maintained and that they receive appropriate medical attention promptly. Throat culture collection involves swabbing the throat to identify the infectious agent and is not a priority in this urgent situation.
Choice D reason:
Administering epinephrine IM is not indicated for suspected epiglottitis. Epinephrine is typically used to treat severe allergic reactions (anaphylaxis) and not for managing epiglottitis. The primary focus in epiglottitis is securing the airway and providing appropriate medical treatment, which might include antibiotics and respiratory support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Experiences separation anxiety - This is a common behavior seen in toddlers during hospitalization. Being away from their parents or caregivers and being in an unfamiliar environment can lead to feelings of anxiety and distress. Separation anxiety is a natural response for young children who rely on their primary caregivers for comfort and security.
Choice B reason:
Fears a loss of control - Toddlers may feel overwhelmed and fearful when they find themselves in a hospital setting. The loss of control over their daily routines and environment can be frightening for them. They may be unable to understand the reasons behind medical procedures or interventions, further increasing their anxiety.
Choice C reason:
Feels hospitalization is punishment - While some children might have difficulty understanding the reasons for hospitalization, it is less common for them to perceive it as punishment.
Children at this age often lack the cognitive capacity to associate their illness with punishment.
Choice D reason:
Develops body image disturbance - Body image disturbance is not a typical behavior observed in toddlers during hospitalization. This issue is more common in older children or adolescents who may experience changes in their appearance due to medical conditions or treatments.
Correct Answer is C
Explanation
"I should call my provider if I notice thick white discharge in my underwear.”
Choice A reason:
The client stating, "I will need to have this device replaced every 3 years,” is incorrect. Subdermal progesterone contraception devices, such as Nexplanon, can typically last for up to 3 years, not needing replacement within that time frame. The rationale behind this is that these devices release a steady amount of progesterone to prevent pregnancy, and they are designed to be effective for the specified duration.
Choice B reason:
The statement, "This device will protect me from STIs,” in Choice B is incorrect. Subdermal progesterone contraception devices do not provide protection against sexually transmitted infections (STIs). Their primary function is to prevent pregnancy by inhibiting ovulation, thickening cervical mucus, and altering the uterine lining, but they do not offer any defense against STIs. It is essential for the client to understand that barrier methods, such as condoms, are necessary for STI protection.
Choice C reason:
The correct answer, "I should call my provider if I notice thick white discharge in my underwear,” is an accurate statement. Thick white discharge could be indicative of a vaginal infection, such as yeast infection, which might require medical attention. It is crucial for the client to report any changes in vaginal discharge to their healthcare provider for proper evaluation and treatment.
Choice D reason:
The statement in Choice D, "I need to decrease the amount of milk I drink while I have this device,” is incorrect. There is no association between subdermal progesterone contraception devices and milk consumption. The device does not interfere with dairy intake or affect its metabolism. This information is unrelated to the proper use or management of the contraception device.
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