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. 1 cup cooked rice: This exceeds the 1 oz serving size and is more than what the nurse is recommending.
B. Flour tortilla: The size of a flour tortilla can vary, but it often exceeds the 1 oz serving size, so it may provide more than the recommended amount.
C. 1 cup ready-to-eat cereal flakes: The volume of cereal can vary, and 1 cup of cereal may provide more than 1 oz of grains, depending on the type and density of the cereal.
D. 1 slice whole wheat bread: A standard slice of whole wheat bread typically provides around 1 oz of grains, making it an appropriate choice for the recommended serving size.
Correct Answer is B
Explanation
A. It is inconclusive
Explanation: A serum phenylalanine level within the normal range is considered conclusive in ruling out phenylketonuria. Inconclusive results typically occur when there are issues with the sample or testing process.
B. It is negative
Explanation:
A serum phenylalanine level of 1 mg/dL (60.5 mcmol/L) in a 2-week-old infant is within the normal range. In the context of phenylketonuria (PKU) screening, a "negative" result means that the phenylalanine levels are within the expected range, and there is no evidence of phenylketonuria.
C. It requires rescreening at age 6 weeks.
Explanation: If the initial screening result is within the normal range, rescreening at age 6 weeks may not be necessary for phenylketonuria. The timing and need for rescreening may vary based on local protocols and individual patient factors.
D. It is positive
Explanation: A positive result for phenylketonuria would indicate that the serum phenylalanine levels are elevated, suggesting a potential diagnosis of PKU. In this case, the result is negative, meaning there is no evidence of PKU.
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