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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Remove the window and view the incision. Inspecting the incision through the cast window is important for monitoring for signs of infection or complications, but it is not the first priority. Ensuring the extremity has adequate circulation and function is critical initially.

B. Medicate the client for pain. Pain management is essential, especially postoperatively, but assessing the integrity and function of the affected extremity takes precedence to ensure there are no immediate complications like compromised circulation or nerve damage.

C. Perform neurovascular checks of the affected extremity. Performing neurovascular checks is the highest priority to ensure that circulation, sensation, and movement are intact. This helps identify any immediate issues with the cast or complications from surgery that could jeopardize the limb’s health.

D. Turn the client so the cast will dry on all sides. Ensuring the cast dries properly is important to maintain its integrity and effectiveness, but this action is secondary to assessing neurovascular status to prevent serious complications.

A. "He takes his medication between meals with water." B. "He only sleeps about 5 hours each night." C. "He seems to be getting a lot more bumps and bruises lately." D. "He has not been eating as much lately."

Correct Answer is C

Explanation

A. "He takes his medication between meals with water." Taking carbamazepine with food helps reduce gastrointestinal upset, but taking it between meals is not critical unless there are specific issues. This is not a priority unless the patient is experiencing significant GI discomfort.

B. "He only sleeps about 5 hours each night." Insufficient sleep can exacerbate seizure disorders, but it is not directly life-threatening. Improving sleep hygiene is important but not the most immediate concern compared to other symptoms.

C. "He seems to be getting a lot more bumps and bruises lately." Increased bruising can indicate thrombocytopenia, a potential side effect of carbamazepine, which can lead to serious bleeding issues. This is the priority as it may indicate a severe adverse effect requiring immediate medical attention and possible adjustment of medication.

D. "He has not been eating as much lately." Decreased appetite can be a side effect of many medications, including carbamazepine, but it is generally not immediately dangerous unless it leads to significant weight loss or nutritional deficiencies. It’s important but not the most urgent concern.

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A nurse is caring for a preschooler who has epiglottitis from a streptococcal infection. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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