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
The fracture does not cross through the bone. Choice A reason:
The statement in Choice A is incorrect because it describes a greenstick fracture as the bone bending and causing a microscopic fracture line. This is not true for a greenstick fracture. A greenstick fracture is an incomplete fracture where the bone bends and partially breaks on one side while remaining intact on the other side. The rationale for this is that pediatric bones are more flexible than adult bones, and when a force is applied, they tend to bend rather than completely break.
Choice B reason:
Choice B is the correct answer. A greenstick fracture does not cross through the bone; it involves only one side of the bone being broken while the other side remains intact. This type of fracture is common in children because their bones are still developing and contain more collagen, making them more flexible and prone to bending rather than breaking completely.
Choice C reason:
The statement in Choice C is incorrect because it describes a different type of fracture. A compressed fracture involves the bone being crushed or shortened, leading to a raised area at the fracture site. This is not characteristic of a greenstick fracture, which involves bending and partial breakage rather than compression.
Choice D reason:
The statement in Choice D is incorrect because it describes a complete fracture that completely divides the bone into two separate pieces. A greenstick fracture, as explained earlier, is an incomplete fracture and does not completely divide the bone.
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).
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