A nurse is admitting a child who has acute epiglottitis. Which of the following actions should the nurse take?

Obtain a throat culture.

Initiate droplet isolation precautions.

Assist the child into a supine position.

Check oxygen saturation every 4 hr.

Answer and Explanation

The Correct Answer is B

The nurse should initiate droplet isolation precautions when admitting a child who has acute epiglottitis.

Epiglottitis is commonly caused by Haemophilus influenzae type B and can be transmitted through respiratory droplets.

Choice A is wrong because obtaining a throat culture is not recommended when epiglottitis is suspected, as it can cause further obstruction of the airway.

Choice C is wrong because assisting the child into a supine position can worsen the airway obstruction.

Children with epiglottitis prefer to sit upright with the chin extended and mouth open.

Choice D is wrong because checking oxygen saturation every 4 hours may not be frequent enough for a child with acute epiglottitis who may require continuous monitoring of oxygen saturation.

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Correct Answer is D

Explanation

An increased respiratory rate is a sign of severe dehydration in infants.

Dehydration occurs when an infant loses so much body fluid that they are not able to maintain ordinary function.

Choice A is wrong because hypertension is not a sign of severe dehydration in infants.

Choice B is wrong because increased urine output is not a sign of severe dehydration in infants.

In fact, decreased urine output is a sign of dehydration 2.

Choice C is wrong because a capillary refill of 2 seconds is normal and not a sign of severe dehydration in infants.

A. "The medication isn't bad. It tastes like candy.” B. "Let me know when you want to take the medication.” C. "The medication will treat your hypersensitivity reaction.” D. "Sometimes, when a child has to take medication, they feel sad.”

Correct Answer is C

Explanation

This statement provides the child with factual information about the purpose of the medication and why it is important for them to take it.

Choice A is wrong because it may not be true that the medication tastes like candy and could lead to mistrust.

Choice B is wrong because it does not address the urgency of taking a stat dose of medication.

Choice D is wrong because it does not provide any information about the purpose of the medication and may not be relevant to the child’s feelings.

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A nurse is admitting a child who has acute epiglottitis. Which of the following actions should the nurse take?

Nursing Test Bank

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