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. "Has the child had any difficulty swallowing food?"
Explanation:
One potential long-term effect of cleft palate repair is difficulty with swallowing or feeding. Cleft palate repair aims to improve the child's ability to eat and speak, but some children may continue to face challenges with swallowing or have a history of difficulty feeding.
B. "Does the child play with an imaginary friend?"
Explanation: Imaginary play is not specifically related to the long-term effects of cleft palate repair. This question does not provide information about the physical outcomes of the surgical repair.
C. "Does the child respond when called by name?"
Explanation: Responsiveness to being called by name is a general developmental question but does not specifically address the long-term effects of cleft palate repair.
D. "Was the child recently treated for pneumonia?"
Explanation: While respiratory issues can be associated with cleft palate, this question focuses on a recent event rather than the long-term effects. Asking about difficulty swallowing or feeding may provide more information about ongoing concerns related to the cleft palate repair.
Correct Answer is D
Explanation
A. Brachial artery:
Incorrect: The brachial artery is commonly used for measuring blood pressure in infants but not for assessing heart rate.
B. Radial artery:
Incorrect: The radial artery is not typically used for assessing an infant's heart rate, especially in the clinical setting.
C. Carotid artery:
Incorrect: The carotid artery is not commonly used for assessing an infant's heart rate. It is more commonly used in adults, but in infants, the apex of the heart is the preferred site.
D. Apex of the heart.
Correct Answer: The apex of the heart is the most accurate site for counting an infant's heart rate. It is located at the point of maximum impulse (PMI), which is usually at the fifth intercostal space in the mid-clavicular line.
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