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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. An infectious disease of the central nervous system
Explanation: Cerebral palsy is not caused by an infectious disease of the central nervous system. It is a non-progressive neurological disorder that arises from brain damage, often during prenatal development.
B. An inflammation of the brain as a result of a viral illness
Explanation: While inflammation of the brain due to a viral illness can lead to neurological complications, cerebral palsy is not specifically caused by inflammation resulting from a viral illness.
C. A chronic disability characterized by impaired muscle movement and posture
Explanation:
Cerebral palsy is a chronic condition that primarily affects motor function and posture. It results from damage to the developing brain, often occurring before or during birth. The impaired muscle movement and posture associated with cerebral palsy can lead to limitations in activities of daily living and mobility.
D. A congenital condition that results in moderate to severe intellectual disabilities
Explanation: Cerebral palsy primarily affects motor function, and intellectual disabilities are not an inherent component of cerebral palsy. While some individuals with cerebral palsy may have associated cognitive impairments, it is not a defining characteristic of the disorder.
Correct Answer is B
Explanation
A. Test the urine for protein.
Explanation: Testing urine for protein is not a priority nursing intervention in the preoperative period for an infant with hydrocephalus. The focus is on preventing complications related to immobility and positioning.
B. Reposition the infant frequently.
Explanation:
Repositioning the infant frequently is a crucial intervention to prevent complications such as pressure ulcers (bedsores). Infants with hydrocephalus may be at an increased risk of skin breakdown due to prolonged immobility and pressure on specific areas. Repositioning helps distribute pressure, improves circulation, and reduces the risk of skin breakdown.
C. Assess blood pressure every 15 minutes.
Explanation: While monitoring blood pressure is important in certain situations, it is not typically the priority for an infant with hydrocephalus in the preoperative period. The focus is on preventing skin breakdown through repositioning.
D. Provide a stimulating environment.
Explanation: While providing a stimulating environment can be beneficial for infant development, it is not the priority in the preoperative period for an infant with hydrocephalus. The primary concern is addressing potential complications related to immobility, such as skin breakdown.
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