A nurse is planning care for a toddler who has epiglottitis.

Which of the following interventions should the nurse include?

Assess the child for frequent swallowing.

Continuously monitor the child’s respiratory status.

Carefully suction the child’s oropharynx to remove secretions.

Administer pancreatic enzymes with meals.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. Continuously monitor the child’s respiratory status. This is because epiglottitis is a life-threatening condition that can cause severe airway obstruction and respiratory distress in children. The nurse should monitor the child for signs of worsening breathing, such as stridor, cyanosis, restlessness, or drooling. The nurse should also be prepared to assist with intubation or tracheostomy if needed.

Choice A is wrong because assessing the child for frequent swallowing may increase the risk of vomiting and aspiration. Swallowing may also be difficult and painful for the child due to the inflammation of the epiglottis.

Choice C is wrong because suctioning the child’s oropharynx may cause more swelling and irritation of the epiglottis, or trigger a spasm that can close off the airway. The nurse should avoid any stimulation of the throat or mouth that may worsen the condition.

Choice D is wrong because administering pancreatic enzymes with meals is not relevant to epiglottitis. Pancreatic enzymes are used to treat cystic fibrosis, a genetic disorder that affects the lungs and digestive system. Epiglottitis is caused by a bacterial infection or an injury to the throat.

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Correct Answer is D

Explanation

The correct answer is d. Evaluate functioning of the suction device.

Choice D rationale:

Prompt assessment of the suction device is crucial to determine if it's functioning properly.If the suction is inadequate,it can lead to gastric contents accumulating and potentially causing vomiting.
Assessing the suction device first allows for timely interventionif it's not working correctly,preventing further complications and discomfort for the client.

Choice A rationale:

Replacing the NG tube might be necessary if it's dislodged or blocked, but it shouldn't be the immediate action.
Evaluating the suction device first can help determine if the NG tube itself is the issue or if the problem lies with the suction.

Choice B rationale:

Providing oral hygiene care is important for comfort and to prevent aspiration, but it's not the priority intervention in this situation.
Addressing the cause of the vomiting, which could be related to suction malfunction, takes precedence.

Choice C rationale:

Administering an antiemetic might be helpful to control nausea and vomiting, but it doesn't address the underlying cause.
Evaluating the suction device first is essential to ensure proper gastric decompression and prevent further vomiting episodes.

A. Elevated pain level. B. Increased drowsiness. C. Frequent swallowing. D. Diminished breath sounds.

Correct Answer is C

Explanation

The correct answer is choice C, frequent swallowing.

This indicates that the child may be experiencing hemorrhage because they are trying to clear the blood from their throat. Frequent swallowing is one of the initial signs of bleeding immediately after tonsillectomy.

Choice A is wrong because elevated pain level is not a specific sign of hemorrhage.

Pain is expected after a tonsillectomy and can be managed with medication and fluids.

Choice B is wrong because increased drowsiness is not a specific sign of hemorrhage.

Drowsiness can be caused by anesthesia, medication, or dehydration.

Choice D is wrong because diminished breath sounds are not a specific sign of hemorrhage.

Diminished breath sounds can be caused by respiratory infection, asthma, or bronchospasm.

Normal ranges for hemoglobin and hematocrit are 11.5 to 15.5 g/dL and 34 to 45% for children, respectively.

Normal ranges for platelet count are 150,000 to 450,000/mm3 for both children and adults.

Normal ranges for plasma clotting variables depend on the specific test and method used.

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A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?

Correct Answer is D

Explanation

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

Correct Answer is C

Explanation

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A nurse is planning care for a toddler who has epiglottitis.

Which of the following interventions should the nurse include?