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.

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Correct Answer is B

Explanation

Choice A reason:

The nurse should not recommend drinking warm tea before bed for a pregnant client. Certain herbal teas might not be safe during pregnancy, and caffeine-containing teas should be limited due to their potential effects on the fetus. Therefore, it is best to avoid suggesting this option to the client.

Choice B reason:

This is the correct choice as relaxation exercises can be beneficial for pregnant clients who are experiencing difficulty sleeping. These exercises can help reduce stress, promote relaxation, and improve sleep quality without any adverse effects on the client or the baby.

Choice C reason:

The nurse should avoid recommending that the client sleep on their right side. While the left side is generally recommended during pregnancy to improve blood flow to the placenta and baby, sleeping on the right side is not harmful either. However, it is better to provide the most suitable option for promoting sleep, which is relaxation exercises as mentioned in Choice B.

Choice D reason:

Soaking in a hot tub for 60 minutes is not advisable during pregnancy. Prolonged exposure to high temperatures, such as in hot tubs or saunas, can raise the body's core temperature, potentially causing harm to the developing fetus. Pregnant individuals should avoid hot tubs to prevent overheating.

A. You should offer your child sips of clear liquids. B. You should gently restrain your child using both of your arms. C. You should place your child's head on a pillow. D. You should give rectal diazepam to your child at the onset of the seizure.

Correct Answer is C

Explanation

Choice A reason:

The nurse should not offer the child sips of clear liquids during a seizure. During a tonic-clonic seizure, the child's swallowing reflex may be impaired, and giving liquids could lead to aspiration or choking, causing further complications.

Choice B reason:

The nurse should not restrain the child during a seizure using both arms or any other means. Restraint can potentially lead to injury for both the child and the person attempting to restrain them. It is crucial to allow the child to move freely during the seizure to prevent harm.

Choice C reason:

Placing the child's head on a pillow is the correct choice. This positioning helps to protect the child's head from injury during the seizure. The pillow provides a cushioning effect, minimizing the risk of head trauma.

Choice D reason:

The nurse should not instruct the parent to give rectal diazepam to the child at the onset of the seizure unless specifically prescribed by the child's healthcare provider. Diazepam is a medication used to manage seizures, but its administration route and timing should be determined by the child's healthcare provider. Inappropriate use of medication can be dangerous and ineffective.

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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

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