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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Using an electronic messaging system to remind clients when to take medications. Tertiary prevention in healthcare involves measures taken to reduce the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries in order to improve as much as possible their ability to function, their quality of life, and their life expectancy. In the context of an HIV clinic, reminding clients to take their medications can help manage the disease effectively and prevent complications.
Choice A rationale:
Educating clients about contraindications to specific immunizations is incorrect because this is more aligned with primary prevention, which aims to prevent the onset of an illness or injury before the disease process begins.
Choice C rationale:
Providing clients with information about the benefits of exercise is incorrect as this is generally considered a part of primary prevention, promoting general health to prevent various diseases.
Choice D rationale:
Helping clients understand health screenings covered by their insurance plans is incorrect because this is typically associated with secondary prevention, which involves screening to identify diseases in the earliest stages.
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.
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