A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take
Obtain a throat culture.
Visualize the epiglottis with a tongue depressor
Place the child in an upright position
Transport the child to radiology for a throat x-ray
The Correct Answer is C
A. Obtaining a throat culture and B. visualizing the epiglottis with a tongue depressor are not safe actions for the nurse to perform without appropriate medical equipment and expertise. These actions can trigger a sudden airway obstruction in a child with epiglottitis. The priority is to ensure airway patency and seek immediate medical assistance.
C. Place the child in an upright position.
Suspected epiglottitis is a medical emergency that can result in rapid airway obstruction. Placing the child in an upright position helps improve airflow by allowing the throat to open and reduces the risk of complete airway obstruction. It's important not to perform invasive procedures (such as throat culture or visualization of the epiglottis) without proper medical equipment and expertise, as these actions can lead to worsening airway obstruction.
D. Transporting the child to radiology for a throat x-ray is not appropriate in this situation, as it may delay necessary interventions to secure the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
In transposition of the great vessels (TGV), the aorta and the pulmonary artery are switched, causing oxygen-rich blood to be pumped back to the lungs and oxygen-poor blood to be pumped out to the body. The ductus arteriosus, a fetal blood vessel that normally closes shortly after birth, allows blood to mix between the two circulations.
Prostaglandin E1 is used to keep the ductus arteriosus open, allowing for a controlled mixing of oxygenated and deoxygenated blood, which can improve oxygen delivery to the body in cases of TGV. This helps maintain oxygenation until corrective surgical interventions can be performed.
The other options, A (decrease pulmonary congestion), B (stimulate the production of red blood cells), and D (increase blood flow to the system), do not accurately describe the primary purpose of Prostaglandin E1 in the context of TGV. The main goal is to maintain a pathway for oxygenated blood to mix with deoxygenated blood to improve oxygen delivery to the body.
Correct Answer is B
Explanation
A. Alertness as such weight loss is not expected: This response may unnecessarily alarm the mother when, in fact, some weight loss in the early days is normal.
B. Reassurance as this is a normal weight loss.
It is normal for newborns to lose some weight during the first few days of life. The loss is often related to fluid loss, changes in feeding patterns, and initial adjustment to life outside the womb. A loss of one-half pound in a 2-day-old neonate is generally considered within the normal range. It's important for the nurse to reassure the new mother that this weight loss is expected and not a cause for alarm. Newborns typically start to regain their birth weight within a week or two. This reassurance can help ease the mother's distress and anxiety.
C. Alarm as this is a drastic weight loss: Characterizing this weight loss as "drastic" is not accurate or helpful and would likely increase the mother's anxiety.
D. Concern as this may be an indicator of inadequate nutrition: Jumping to the conclusion of inadequate nutrition without further assessment and evidence is premature and may unnecessarily worry the mother. It's important to start with reassurance and then investigate if there are concerns about nutrition.
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