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 B

Explanation

B) I can visit my nephew who has chickenpox 5 days after the sores have crusted.

This statement indicates an understanding of infection prevention because it demonstrates knowledge about the contagious period of chickenpox. Visiting someone with chickenpox after the sores have crusted is a safe practice, as the person is no longer contagious.

The other options represent misconceptions about infection prevention:

A) Taking antibiotics for a viral infection is not effective, as antibiotics are used to treat bacterial infections, not viruses.

C) This statement is identical to option B and is incorrect.

D) Cleaning a cat's litter box during pregnancy is generally not recommended due to the risk of toxoplasmosis, a parasitic infection that can be transmitted through cat feces. Pregnant individuals are advised to have someone else handle cat litter or to use gloves and wash their hands thoroughly if they must do it themselves.

A. Observe the position of the suspended weight B. Check the client’s pedal pulse on the right leg C. Ask the client to describe her pain D. Remind the client to use the incentive spirometer E. None F. None

Correct Answer is D

Explanation

The correct answer is D. Remind the client to use the incentive spirometer.

Choice A rationale:

Observing the position of the suspended weight is beyond the scope of practice for assistive personnel (AP). This task requires assessment skills to ensure proper alignment and functioning of the traction system, which is the responsibility of the nurse.

Choice B rationale:

Checking the client’s pedal pulse on the right leg involves assessment and clinical judgment to evaluate perfusion and detect potential complications such as impaired circulation. This is not a task that can be delegated to AP.

Choice C rationale:

Asking the client to describe her pain requires assessment and interpretation of subjective data, which falls under the nurse's scope of practice. Pain assessment is a critical nursing function.

Choice D rationale:

Reminding the client to use the incentive spirometer is a non-assessment task that involves reinforcing previously taught instructions. This is appropriate to delegate to assistive personnel, as it does not require clinical judgment.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching

Correct Answer is B

Explanation

A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

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

Which of the following interventions should the nurse include?