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 B
Explanation
A. "I am unable to discuss this, but I can contact my supervisor to speak with you."
Explanation: While it is appropriate to involve a supervisor in difficult situations, the nurse should first clarify the legal obligation to report suspected child abuse. This response may leave the impression that the nurse is avoiding the question.
B. "As a nurse, I am required by law to report suspected child abuse."
Explanation:
Nurses are mandated reporters, meaning they are legally obligated to report suspected child abuse. It is important to communicate this legal obligation to the parents when they inquire about the reason for the report. This response is honest, direct, and reinforces the nurse's ethical and legal responsibility to prioritize the well-being and safety of the child.
C. "I reported the incident to my supervisor who decided to contact the authorities."
Explanation: This response may create confusion about the reporting process. It is important to convey that reporting is a legal obligation for the nurse, and it is not solely at the discretion of the supervisor.
D. "The provider will be coming to explain the situation."
Explanation: While involving other healthcare professionals, such as a provider, may be part of the process, it is crucial to emphasize the nurse's legal responsibility to report suspected child abuse. This response does not clearly communicate the legal obligation that the nurse has in reporting such incidents.
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."
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