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 ["A","C","D"]
Explanation
A. Lateral deviation and rotation of each vertebra:
Correct Answer: Correct.
Explanation: Scoliosis involves a lateral (side-to-side) curvature of the spine and often includes some degree of vertebral rotation. Assessing for these deviations is crucial in diagnosing scoliosis.
B. Equal rib prominences:
Correct Answer: Incorrect.
Explanation: In scoliosis, the ribs may appear more prominent on one side due to the lateral curvature of the spine. Therefore, equal rib prominences would not typically be observed in scoliosis.
C. Unequal rib heights:
Correct Answer: Correct.
Explanation: Unequal heights of the ribs are commonly seen in scoliosis due to the asymmetrical nature of the spine's curvature.
D. Chest asymmetry:
Correct Answer: Correct.
Explanation: Asymmetry in the chest area, including differences in the shape or appearance of the chest, can be indicative of scoliosis, especially when associated with the spinal curvature.
E. Equal shoulder heights:
Correct Answer: Incorrect.
Explanation: In scoliosis, one shoulder might appear higher than the other due to the lateral curvature of the spine. Therefore, equal shoulder heights would not typically be observed in scoliosis.
F. Equal waist angles:
Correct Answer: Incorrect.
Explanation: Scoliosis often causes an asymmetrical appearance of the waistline due to the lateral curvature of the spine, resulting in unequal waist angles rather than equal ones.
Correct Answer is B
Explanation
A. Cranberry juice
Explanation: Acidic and citrus juices, including cranberry and orange juice, should be avoided in the immediate postoperative period as they can be irritating to the surgical site and may increase the risk of bleeding.
B. Crushed ice
Explanation:
After a tonsillectomy, it's important to provide cold and clear fluids to soothe the throat and prevent bleeding. Crushed ice is a suitable option as it helps keep the throat cool and provides hydration without irritating the surgical site. Cold liquids can help minimize swelling and provide comfort.
C. Vanilla milkshake
Explanation: While milkshakes may be appealing, dairy products can coat the throat and may not be recommended immediately after surgery. Additionally, it's crucial to avoid using straws, as sucking can increase the risk of bleeding.
D. Orange juice
Explanation: As mentioned earlier, citrus juices like orange juice can be irritating to the surgical site and are not recommended in the early postoperative period after a tonsillectomy. It's essential to choose clear and non-acidic fluids to support healing and prevent complications.
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