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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason:

If the parent states, "My child uses scissors to cut out the outline of an object,” this indicates fine motor skills development. While this is a positive milestone, it is not specific to the expected benchmarks of other preschoolers in this age group. The ability to cut out shapes with scissors varies widely among preschoolers.

Choice B reason:

"My child can copy triangle shapes onto paper.” This statement shows that the child can demonstrate some level of visual-motor coordination and fine motor skills. Copying shapes like triangles is a common milestone for many preschoolers at the age of 3 and is considered an expected benchmark.

Choice C reason:

If the parent says, "My child can ride a tricycle,” this indicates gross motor skills development. Riding a tricycle is also a milestone achieved by many preschoolers, but it may not be as specific to the expected benchmarks of this age group as choice B, which focuses on fine motor skills and visual-motor coordination.

Choice D reason:

If the parent mentions, "My child can throw a ball overhead,” this also points to gross motor skills development. While throwing a ball overhead is an impressive skill for a 3-year-old, it may not be as common or consistent among all preschoolers in this age group as the ability to copy triangle shapes onto paper (choice B).

A. Reinforce to the client that they should not breastfeed after delivery. B. Maintain contact precautions for the client. C. Obtain a pharyngeal culture from the client. D. Reinforce to the client that they will receive IV antibiotic prophylaxis.

Correct Answer is D

Explanation

Choice A reason:

The nurse should not reinforce to the client that they should not breastfeed after delivery. Group B streptococcus (GBS) is not transmitted through breast milk. It is crucial for infants born to GBS-positive mothers to receive appropriate prophylaxis, but breastfeeding is not contraindicated.

Choice B reason:

The nurse should maintain contact precautions for the client. Group B streptococcus is a highly contagious bacterium, and taking precautions can help prevent its transmission to other patients and healthcare workers.

Choice C reason:

The nurse does not need to obtain a pharyngeal culture from the client. Group B streptococcus colonization typically occurs in the genital and gastrointestinal tracts, not in the pharynx. Therefore, a pharyngeal culture would not be relevant in this situation.

Choice D reason:

This is the correct action the nurse should take. The client tested positive for group B streptococcus, which puts the newborn at risk of infection during labor and delivery. The standard protocol is to administer intravenous antibiotic prophylaxis to the mother during labor to reduce the risk of transmission to the baby.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing growth and development milestones with the parents of a 3-year-old preschooler. Which of the following statements by a parent indicates to the nurse that the preschooler is meeting the expected benchmarks of other preschoolers in this age group?

Correct Answer is B

Explanation

A nurse is caring for a client who is in labor and tested positive for group B streptococcus B- hemolytic. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is collecting data from a school-age child who has a newly diagnosed brain tumor. Which of following findings should the nurse expect?

A nurse is reinforcing teaching with a parent of a child who has a greenstick fracture. Which of the following information should the nurse include in the teaching?

A nurse is preparing to administer an intermittent enteral feeding to a child who has an NG tube in place. Which of the following actions should the nurse take first?

A nurse is contributing to the plan of care for a client who is in the third trimester and reports difficulty sleeping. Which of the following statements should the nurse include?

A nurse is reinforcing teaching with a client who is postpartum and is taking docusate sodium to prevent constipation. Which of the following instructions should the nurse include?

A nurse is contributing to the plan of care for a client 48 hr following cesarean birth. Which of the following nonpharmacologic interventions should the nurse include to reduce pain from intestinal gas?

A nurse is assisting in the care of a child who is receiving IV cefuroxime when the child begins to have difficulty breathing. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching about perception of death with the guardians of an adolescent who has a terminal illness. Which of the following statements should the nurse make?