A nurse is admitting a child who has suspected epiglottitis. Which of the following actions should the nurse take first?
Administer 0,9% sodium chloride IV solution.
Assist with obtaining an x-ray of the child's neck
Initiate IV antibiotics.
Place the child on droplet precautions
The Correct Answer is D
A. Administer 0.9% sodium chloride IV solution: Although IV fluids might be necessary to maintain hydration and circulation, this is not the priority over preventing the spread of infection.
B. Assist with obtaining an x-ray of the child's neck. Imaging can help confirm the diagnosis but should be done after ensuring infection control measures.
C. Initiate IV antibiotics. Antibiotics are crucial for treatment but should follow the implementation of droplet precautions to prevent the spread of infection.
D. Place the child on droplet precautions.
Epiglottitis is a medical emergency primarily caused by bacterial infections, such as Haemophilus influenzae type B (Hib). The first priority is to ensure the safety of both the patient and others by preventing the spread of infection. Placing the child on droplet precautions helps to contain the bacteria and protect healthcare workers and other patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "This shunting allows oxygenated and unoxygenated blood to mix."
Explanation: This statement is correct. In PDA, the shunting of blood between the aorta and pulmonary artery allows oxygenated and unoxygenated blood to mix, leading to decreased oxygen saturation in the systemic circulation.
B. "Blood is shunted to the right side of the heart."
Explanation: This statement is correct. In PDA, blood is shunted from the left side of the heart (aorta) to the right side of the heart (pulmonary artery).
C. "This shunting results in increased pulmonary blood flow."
Explanation: This statement is correct. PDA leads to increased pulmonary blood flow as a result of the shunting of blood from the aorta to the pulmonary artery.
D. "Blood is shunted to the left side of the heart."
Explanation:
A patent ductus arteriosus (PDA) is a congenital heart defect where the ductus arteriosus, a fetal blood vessel that normally closes shortly after birth, remains open. In PDA, blood is shunted from the aorta (left side of the heart) to the pulmonary artery (right side of the heart), resulting in increased pulmonary blood flow. Therefore, the correct statement is that "Blood is shunted to the right side of the heart."
Correct Answer is D
Explanation
A. Brachial artery:
Incorrect: The brachial artery is commonly used for measuring blood pressure in infants but not for assessing heart rate.
B. Radial artery:
Incorrect: The radial artery is not typically used for assessing an infant's heart rate, especially in the clinical setting.
C. Carotid artery:
Incorrect: The carotid artery is not commonly used for assessing an infant's heart rate. It is more commonly used in adults, but in infants, the apex of the heart is the preferred site.
D. Apex of the heart.
Correct Answer: The apex of the heart is the most accurate site for counting an infant's heart rate. It is located at the point of maximum impulse (PMI), which is usually at the fifth intercostal space in the mid-clavicular line.
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