A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include?
Continuously monitor the child's respiratory status.
Administer pancreatic enzymes with meals.
Assess the child for frequent swallowing.
Carefully suction the child's oropharynx to remove secretions.
The Correct Answer is A
A. Correct. Epiglottitis can cause airway obstruction, so continuous respiratory monitoring is crucial to detect any signs of respiratory distress.
B. Incorrect. Administering pancreatic enzymes is not relevant to epiglottitis.
C. Incorrect. Frequent swallowing assessment is not the priority for epiglottitis. Airway management is.
D. Incorrect. Suctioning may be necessary, but continuous respiratory monitoring takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should instruct the parents to report sudden, persistent headaches in a child with sickle cell anemia because it could be a sign of a cerebrovascular accident (stroke) Sickle cell anemia predisposes individuals to vaso-occlusive crises, which can lead to stroke due to impaired blood flow. Early detection and intervention are crucial in preventing complications.
Choice B rationale:
Applying cold compresses to painful areas may help in managing pain during vaso-occlusive crises, but it is not as critical as identifying signs of more severe complications such as stroke. This instruction does not address the urgency of reporting sudden, persistent headaches.
Choice C rationale:
Restricting fluid intake during times of stress is not appropriate for a child with sickle cell anemia. In fact, maintaining adequate hydration is important to prevent vaso-occlusive crises. Dehydration can exacerbate sickling of red blood cells, leading to more pain and complications.
Choice D rationale:
Avoiding meningococcal immunizations is not appropriate for a child with sickle cell anemia. In fact, children with sickle cell disease are at an increased risk of infections, including meningitis. Immunizations, including those for meningococcus, are essential to prevent life-threatening infections in these individuals.
Correct Answer is D
Explanation
A. Incorrect. Postural drainage is usually performed multiple times a day, usually three to four times, to effectively mobilize respiratory secretions.
B. Incorrect. Percussions are typically performed using cupped hands to create vibrations. Holding the hand flat would not produce the desired effect.
C. Bronchodilator should be administered PRIOR to procedure if prescribed
D. Postural drainage should be performed before meals or at least 1-2 hours after meals to prevent vomiting or aspiration.
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