The nurse in the emergency department is caring for a child who appears extremely ill with a high fever, unable to control their oral secretions. with voice hoarseness and inspiratory stridor and inspiratory sternal retractions while breathing. The nurse suspects epiglottitis. Which would the nurse do next?
Contact the assigned emergency room physician to evaluate the need for an advanced airway
Administer intravenous corticosteroids
Obtain a throat culture
inspect the throat to obtain further data to support the diagnosis
The Correct Answer is A
A. Contact the assigned emergency room physician to evaluate the need for an advanced airway
Explanation:
Epiglottitis is a medical emergency that can rapidly progress to airway obstruction. The classic signs and symptoms include a high fever, difficulty swallowing, voice hoarseness, inspiratory stridor, and sternal retractions. Immediate intervention may be necessary to secure the airway. Therefore, contacting the emergency room physician to evaluate the need for an advanced airway (such as intubation) is a priority.
B. Administer intravenous corticosteroids
Explanation: While corticosteroids may be used in the management of epiglottitis to reduce airway inflammation, securing the airway is the priority in the acute phase. Corticosteroids would typically be administered after securing the airway.
C. Obtain a throat culture
Explanation: Obtaining a throat culture is not the immediate priority in the case of suspected epiglottitis. Prompt intervention to secure the airway takes precedence over diagnostic tests.
D. Inspect the throat to obtain further data to support the diagnosis
Explanation: Direct visualization of the throat (inspection) may exacerbate the airway obstruction and is not recommended in the acute management of suspected epiglottitis. The priority is to secure the airway while minimizing agitation and discomfort for the child. Diagnostic procedures, such as obtaining a throat culture, can be considered after the airway is stabilized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Orthopnea
Explanation:
Orthopnea refers to difficulty breathing that occurs when lying flat. In heart failure, fluid may accumulate in the lungs, leading to respiratory distress when the child is in a supine position. Orthopnea is a common symptom of heart failure in both adults and children.
B. Bradycardia
Explanation: Bradycardia (slow heart rate) is not a typical finding in heart failure. Heart failure often leads to compensatory mechanisms, including an increased heart rate (tachycardia), to maintain cardiac output.
C. Weight loss
Explanation: Weight loss is not a typical finding in heart failure. In fact, heart failure in children may lead to fluid retention and weight gain rather than weight loss.
D. Increased urine output
Explanation: Heart failure in toddlers is more likely to be associated with decreased urine output rather than increased urine output. Reduced cardiac output can result in decreased blood flow to the kidneys, leading to decreased urine production and potential fluid retention. Increased urine output is not a characteristic finding in heart failure.
Correct Answer is D
Explanation
A. When a parent is holding the infant
Explanation: Being held by a parent is generally a comforting and calming experience for an infant, and it is unlikely to significantly increase oxygen demand. In fact, the presence of a familiar caregiver may help reduce stress.
B. During sleep
Explanation: During sleep, an infant's oxygen demand may decrease, and oxygen supplementation may not be necessary unless there are specific indications or concerns about oxygen saturation levels.
C. When changing the infant's diapers
Explanation: Changing a diaper is a routine care activity that is not likely to significantly increase oxygen demand. It is not typically associated with stress or increased metabolic activity that would necessitate additional oxygen.
D. When drawing blood for electrolyte level testing
Explanation:
Drawing blood for electrolyte level testing is a potentially stressful procedure that may cause distress and anxiety in the infant. Stress and anxiety can increase the metabolic rate and oxygen demand. In a situation where an infant is already prescribed oxygen as needed for heart failure, additional stressors like blood drawing may necessitate the administration of oxygen to ensure an adequate oxygen supply
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