A nurse is admitting a child who has acute epiglottitis.
Which of the following actions should the nurse take?
Check oxygen saturation every 4 hr.
Obtain a throat culture.
Assist the child into supine position.
Initiate droplet isolation precautions.
The Correct Answer is D
Choice A rationale:
Checking oxygen saturation every 4 hours is a monitoring parameter for patients with respiratory issues but is not the priority in a child with acute epiglottitis. Airway management and infection control are more critical in this situation.
Choice B rationale:
Obtaining a throat culture is important to confirm the diagnosis of epiglottitis. However, initiating isolation precautions and ensuring the child's airway is secure take precedence in the immediate care of a child with acute epiglottitis.
Choice C rationale:
Assisting the child into a supine position is contraindicated in acute epiglottitis. This position can further compromise the airway by obstructing it. The child should be allowed to sit in a position of comfort, usually sitting upright and leaning slightly forward.
Choice D rationale:
Initiating droplet isolation precautions is crucial when dealing with a suspected or confirmed case of epiglottitis. Epiglottitis is highly contagious and is transmitted via respiratory droplets. Isolation precautions help prevent the spread of the infection to others.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choiceb. “We will place the diaper under the straps.”
Choice A rationale:
Adjusting the straps daily is not recommended.The straps should only be adjusted by a healthcare professional to ensure proper fit and effectiveness.
Choice B rationale:
Placing the diaper under the straps is correct.This helps to keep the harness clean and dry, and ensures that the straps remain in the correct position.
Choice C rationale:
The duration of wearing the Pavlik harness is typically longer than 2 weeks.It is usually worn for about 6-12 weeks, depending on the doctor’s recommendation.
Choice D rationale:
Applying lotion to the skin under the straps is not advised as it can cause skin irritation and affect the fit of the harness.
Correct Answer is C
Explanation
Choice A rationale:
Providing frequent range of motion to the neck and shoulders is not appropriate for an infant with bacterial meningitis. Meningitis is an inflammation of the membranes surrounding the brain and spinal cord and can cause severe neck pain and stiffness. Range of motion exercises could exacerbate the discomfort and should be avoided.
Choice B rationale:
Keeping the television on in the room to provide background noise is not appropriate for an infant with bacterial meningitis. Infants with meningitis need a quiet and calm environment to reduce stimuli and promote healing.
Choice C rationale:
Padding the side rails of the crib is important to prevent injury during seizures, which can occur in bacterial meningitis. Seizures can cause uncontrolled movements, and padding the crib rails can prevent the infant from getting hurt during these episodes.
Choice D rationale:
Placing the infant in a semiprivate room is not appropriate for bacterial meningitis. Infants with meningitis need isolation to prevent the spread of the infection to other patients. They should be placed in a private room with strict infection control measures in place.
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