A nurse is assisting in the care of a newly admitted client.

Which of the following findings should the nurse report immediately to the provider? Select all that apply

A) Request an x-ray of the neck: In cases of suspected epiglottitis, a lateral neck x-ray can help confirm the diagnosis by showing the classic "thumbprint sign," which indicates swelling of the epiglottis. This is a critical diagnostic step, but it should only be performed in a controlled setting where the child’s airway can be monitored closely. The priority is to avoid any procedures that may cause irritation or further compromise the airway.

B) Monitor urine for protein: Monitoring urine for protein is not relevant to the management of epiglottitis. This condition is related to inflammation and obstruction of the upper airway, and the focus should be on respiratory management rather than renal function.

C) Obtain a nasopharyngeal swab: While obtaining a nasopharyngeal swab can help identify the organism causing an infection (often bacterial), it is not the immediate priority in a child with suspected epiglottitis. The child’s airway is the most critical concern, and diagnostic interventions that could potentially cause further distress or obstruction (such as swabbing) should be avoided until airway management is stable.

D) Administer fluconazole: Fluconazole is an antifungal medication, and its use is not appropriate for epiglottitis. Epiglottitis is most often caused by a bacterial infection, particularly Haemophilus influenzae type b (Hib), which requires antibiotic therapy, not antifungals.

A) Irregular heart rate: An irregular heart rate is a key manifestation of hyperkalemia. Elevated potassium levels can interfere with the normal electrical activity of the heart, leading to arrhythmias, which can cause an irregular heart rate. In severe cases, hyperkalemia can lead to life-threatening cardiac events such as ventricular fibrillation or asystole.

B) Dry mucous membrane: Dry mucous membranes are more commonly associated with dehydration, not hyperkalemia. Dehydration can cause fluid volume depletion, which leads to dry mouth and other signs of insufficient hydration. While renal failure can lead to fluid balance issues, dry mucous membranes are not typically linked to elevated potassium levels.

C) Trousseau's sign: Trousseau's sign is a clinical indicator of hypocalcemia, not hyperkalemia. It is a spasm of the hand and wrist that occurs when a blood pressure cuff is inflated above systolic pressure for several minutes. This sign suggests low calcium levels, and while calcium imbalance can occur in renal failure, it is unrelated to hyperkalemia.

D) Hyperactive reflexes: Hyperactive reflexes are more commonly associated with conditions like hypocalcemia, rather than hyperkalemia. In hyperkalemia, the typical findings include muscle weakness or paralysis due to the effect of potassium on muscle and nerve function, but hyperactive reflexes would not be expected.