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. Gently reinsert the tubes. Tympanostomy tubes should not be reinserted by the parent. Inserting the tubes requires medical expertise and should be performed by a healthcare professional to avoid damaging the ear.
B. Call the health care clinic to report that the tubes have fallen out. This is the correct action. The healthcare provider needs to be informed to assess if new tubes are necessary. Tubes may naturally fall out as part of the healing process, but professional evaluation is essential to determine the next steps.
C. Reassure the mother that the tubes will not fall out. It is incorrect to reassure the parent that the tubes will not fall out. Tubes can fall out naturally as the eardrum heals, and parents should be prepared for this possibility and know the appropriate steps to take.
D. Take the child to an emergency department. This is generally not necessary unless there are signs of complications such as severe pain, infection, or significant hearing loss. Routine follow-up at the clinic is sufficient for a non-emergency situation like a tube falling out.
Correct Answer is B
Explanation
A. Hepatitis B (HBV): The Hepatitis B vaccine is typically completed in the infant stage, and a 5-year-old with up-to-date vaccinations would not need a booster for school entry. This is not included in the pre-kindergarten vaccine schedule.
B. Measles, mumps, and rubella (MMR): The MMR vaccine is part of the pre-kindergarten immunization schedule. A second dose is recommended between ages 4 and 6 to ensure immunity before school entry.
C. Haemophilus influenzae type B (Hib): The Hib vaccine is typically administered to infants and young children, and a 5-year-old with up-to-date immunizations would already be fully vaccinated against Hib. No booster is required at this age.
D. Pneumococcal conjugate vaccine (PCV): The PCV vaccine series is usually completed in infancy, and a 5-year-old with current vaccinations would not require a booster. This vaccine is not part of the pre-kindergarten schedule.
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