A nurse is caring for a child with epiglottitis.
Which nursing intervention should the nurse prioritize to maintain a patent airway?

Choice A rationale:

The statement "My throat is really sore.”.

is a common symptom of throat infections, including epiglottitis.

While it is concerning, it is not the most concerning symptom in this case.

Epiglottitis can rapidly progress, leading to respiratory distress, which is a life-threatening condition.

Choice B rationale:

The statement "I can't stop drooling.”.

is a significant concern in a child suspected of having epiglottitis.

Drooling and difficulty managing secretions are hallmark signs of epiglottitis and indicate compromised airway protection.

This symptom suggests that the epiglottis is inflamed and obstructing the airway, potentially leading to respiratory distress and the need for urgent intervention.

Choice C rationale:

The statement "I feel restless and agitated.”.

is a non-specific symptom and may be seen in various illnesses, including infections.

While it indicates the child's discomfort, it does not directly point to the severity of the condition or airway compromise, making it less concerning than the inability to handle secretions.

Choice D rationale:

The statement "I'm having trouble breathing.”.

is the most concerning symptom in a child suspected of having epiglottitis.

Difficulty breathing indicates significant airway obstruction, which can rapidly progress to respiratory failure.

This symptom requires immediate medical attention and intervention to secure the airway and prevent further complications.

Choice A rationale:

Difficulty swallowing and throat pain are common symptoms of epiglottitis, but they do not necessarily indicate the severity of the condition.

Choice B rationale:

Feeling anxious and restless may be a sign of distress, but it does not specifically indicate the severity of epiglottitis.

Choice C rationale:

Making a high-pitched sound when breathing (called stridor) is a serious symptom indicating airway obstruction.

While this is concerning, it is not the most critical manifestation in evaluating the severity of epiglottitis.

Choice D rationale:

Cyanosis, characterized by a bluish discoloration of the skin and lips, indicates severe lack of oxygen and is a critical sign in assessing the severity of epiglottitis.

Cyanosis suggests inadequate oxygenation and is indicative of impending respiratory failure, requiring immediate medical intervention.