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 A
Explanation
A. Ask the child what he knows about the procedure. Understanding the child’s knowledge and feelings about the procedure helps tailor the explanation to address any misconceptions and reduce anxiety. This is the first step in providing appropriate and effective education.
B. Allow the child to see and touch IV tubing and supplies. Familiarizing the child with the equipment can reduce fear, but it is better to first assess what the child knows and address any concerns or fears before showing the supplies.
C. Describe the procedure using visual aids. Using visual aids to explain the procedure is helpful, but it should follow assessing the child’s current understanding to ensure the explanation is appropriate and comprehensive.
D. Explain to the child's parents what role they will have during the procedure. Involving the parents and explaining their role is important, but the child’s understanding and comfort should be addressed first to ensure they are calm and prepared for the procedure.
Correct Answer is B
Explanation
A. Decreased hematocrit: Hematocrit usually increases in dehydration due to the concentration of red blood cells in a smaller volume of plasma.
B. Increased respiratory rate: Dehydration can lead to tachypnea (increased respiratory rate) as the body attempts to compensate for the decreased blood volume and maintain oxygen delivery.
C. Decreased heart rate: Dehydration typically causes tachycardia (increased heart rate) as the body tries to maintain adequate blood circulation and pressure.
D. Increased platelet count: Dehydration does not typically affect platelet count significantly, though it may concentrate blood components, including platelets, making them appear elevated on a lab test.
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