A nurse is caring for a child who has epiglottitis due to an infection with Haemophilus influenzae type B. Which of the following actions should the nurse take? Select all that apply.

Inspect the epiglottis.

Obtain a throat culture.

Monitor oxygen saturation.

Begin droplet precautions.

Initiate IV access.

Answer and Explanation

Correct Answer : C,D,E

A.   Inspecting the epiglottis is contraindicated in suspected cases of epiglottitis as it may trigger laryngospasm and compromise the airway.
B.   Obtaining a throat culture may be indicated to confirm the presence of Haemophilus influenzae type B but is not an immediate priority in the management of epiglottitis.
C.   Monitoring oxygen saturation is crucial as respiratory distress and hypoxia are common complications of epiglottitis.
D.   Beginning droplet precautions is important to prevent the spread of the infectious agent to others.
E.   Initiating IV access is necessary for administering fluids and medications, as well as for potential airway management in severe cases of epiglottitis.

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Correct Answer is A

Explanation

A. Discarding the first voided specimen is necessary to ensure accuracy in a 24-hour urine collection. This helps eliminate any urine that has been in the bladder prior to the start of the collection period.
B. Voiding every hour is not necessary for a 24-hour urine collection. The goal is to collect all urine produced over a 24-hour period, not voiding at set intervals.
C. Cleansing the perineum with a povidone-iodine solution prior to voiding is not typically necessary for a 24-hour urine collection unless specifically instructed by the healthcare provider.
D. Saving the final specimen in a separate container is not necessary for a 24-hour urine collection. All urine produced during the specified collection period should be saved in the same container.

A. Monitor oxygen saturation continuously. B. Restrict oral intake. C. Give oral hydroxyurea. D. Administer meperidine IV for pain. E. Instruct the parent to ensure the pneumococcal vaccine is current. F. Place the client on strict bed rest. G. Administer folic acid as prescribed.

Correct Answer is ["A","C","D","E","G"]

Explanation

A. Continuous monitoring of oxygen saturation is crucial in a vaso-occlusive crisis to detect any signs of hypoxia early, which could exacerbate the crisis and lead to more severe complications. This is important for assessing respiratory status, especially in patients with sickle cell disease who may be at risk for acute chest syndrome.

B. Oral intake should not be restricted during a vaso-occlusive crisis as hydration is important for maintaining adequate blood flow and preventing dehydration.

C. Hydroxyurea is used to reduce the frequency of painful crises in patients with sickle cell disease. It works by increasing the production of fetal hemoglobin, which can help prevent sickle cell crises.

D. Meperidine (Demerol) is an opioid analgesic commonly used to manage severe pain associated with sickle cell crises.

E. Vaccination is important in preventing infections, which can trigger or worsen a vaso-occlusive crisis in individuals with sickle cell disease. Ensuring the pneumococcal vaccine is current helps protect the adolescent from potential infections.

F. Placing the client on strict bed rest can increase the risk of thrombosis and impair circulation.

G. Folic acid supplementation is often recommended for patients with sickle cell disease to support red blood cell production and prevent folate deficiency, which can worsen anemia.

H. Cold compresses are not recommended as they can cause vasoconstriction, worsening the pain and sickling in vaso-occlusive crises. Warm compresses are generally preferred.

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A nurse is caring for a child who has epiglottitis due to an infection with Haemophilus influenzae type B. Which of the following actions should the nurse take? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is providing instructions about a 24-hr urine collection to an adolescent client. Which of the following should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for an adolescent who is admitted with a vaso-occlusive crisis. Exhibits The nurse is planning care for the adolescent. Select the 5 interventions the nurse should include.

Correct Answer is ["A","C","D","E","G"]

Explanation

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