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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "This will not be painful, just a little uncomfortable." While this statement might provide some reassurance, it does not actively engage the child or make the task of taking deep breaths more enjoyable.
B. "Let's play a game of blowing cotton balls across your table." This is the best choice as it makes deep breathing fun and engaging for the child, encouraging them to participate without feeling like it’s a chore.
C. "Do you want to take deep breaths for me now?" This approach is too passive and doesn't engage the child actively or make the activity interesting.
D. "You can't go to the playroom until you finish doing your deep breathing." This approach can create negative reinforcement and might make the child associate deep breathing with punishment or coercion, which is not desirable.
Correct Answer is A
Explanation
A. "My baby's fingers are looking swollen.": Swelling around the IV site can indicate infiltration, where IV fluids leak into surrounding tissues rather than being infused into the vein.
B. "The tape is coming off the IV needle.": While loose tape may need to be replaced, it does not specifically indicate infiltration.
C. "There's blood backing up my baby's IV tubing.": Blood backflow can indicate various issues such as improper placement or the IV being too low, but not necessarily infiltration.
D. "There's a long red streak up my baby's arm.": A red streak can indicate phlebitis, inflammation of the vein, rather than infiltration, which typically presents with swelling and coolness around the IV site.
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