A nurse is caring for a preschooler who has epiglottitis from a streptococcal infection. Which of the following actions should the nurse take?
Attempt to obtain a throat culture.
Use a tongue depressor to observe the back of the throat.
Apply humidified oxygen via a mask.
Initiate airborne precautions.
The Correct Answer is C
A. Attempt to obtain a throat culture: This is contraindicated because manipulating the throat could exacerbate airway obstruction, leading to a potential respiratory emergency.
B. Use a tongue depressor to observe the back of the throat: This can provoke a spasm or cause complete airway obstruction in a child with epiglottitis and should be avoided.
C. Apply humidified oxygen via a mask: This helps to keep the airways moist and can provide some relief and improve oxygenation while minimizing the risk of airway manipulation.
D. Initiate airborne precautions: Epiglottitis primarily requires droplet precautions, not airborne. Airborne precautions are used for diseases like tuberculosis, which are spread through smaller droplets that remain suspended in the air.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. 30 mL: Incorrect. This is far too high; it does not correspond to typical urine output.
B. 1 mL: Correct. It is a standard practice to equate 1 gram of wet diaper weight to 1 mL of urine, providing an accurate measure for fluid balance in infants.
C. 15 mL: Incorrect. This is too high for the given weight-to-volume ratio.
D. 5 mL: Incorrect. This is too high and does not match standard pediatric guidelines.
Correct Answer is D
Explanation
A. Diarrhea: Not typically associated with Wilms' tumor, which affects the kidneys and presents primarily with abdominal symptoms.
B. Jaundice: Not a common symptom of Wilms' tumor, which involves the kidneys and usually does not affect liver function.
C. Swollen joints: This is more associated with conditions such as juvenile arthritis, not Wilms' tumor.
D. Abdominal mass: Wilms' tumor often presents as an asymptomatic abdominal mass that may be discovered during routine physical examination or parental bathing.
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