A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis.
Which of the following actions should the nurse take?
Prepare to assist with intubation.
Prepare a cool mist tent.
Suction the child's oropharynx.
Obtain a throat culture.
The Correct Answer is A
Choice A rationale:
Preparing to assist with intubation is the appropriate action for a nurse caring for a child with suspected epiglottitis. Epiglottitis is a medical emergency where the airway can become severely compromised due to inflammation of the epiglottis. Intubation ensures a secure airway, allowing the child to breathe and preventing respiratory distress.
Choice B rationale:
Preparing a cool mist tent is not the priority in suspected epiglottitis. While humidified air can provide comfort for respiratory distress, it does not address the potential for airway obstruction. Intubation takes precedence in this critical situation.
Choice C rationale:
Suctioning the child's oropharynx may worsen the condition in suspected epiglottitis. Suctioning can stimulate the epiglottis, triggering a spasm and further obstructing the airway. Intubation is the primary intervention to secure the airway safely.
Choice D rationale:
Obtaining a throat culture is not the immediate action in suspected epiglottitis. While a throat culture may confirm the diagnosis, the priority is securing the airway to prevent respiratory distress and hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Acknowledging the difficulty of caring for a terminally ill person is empathetic, but it doesn't offer a solution to the son's problem. The nurse should provide practical assistance or information to help alleviate the son's stress and fatigue.
Choice B rationale:
(Correct Choice) Offering information about respite care is appropriate in this situation. Respite care provides temporary relief to caregivers, allowing them to take a break from their caregiving responsibilities. Providing information about available resources can empower the son to make decisions that support his well-being and the well-being of his mother.
Choice C rationale:
Suggesting a sleeping pill before bed might not be appropriate without a healthcare provider's assessment. Additionally, relying on medication alone might not address the underlying stress and fatigue the son is experiencing.
Choice D rationale:
Praising the son for his caregiving efforts is supportive, but it doesn't offer a solution to his lack of sleep. While encouragement and recognition are important, addressing the son's immediate need for rest and support should be the priority.
Correct Answer is A
Explanation
Choice A rationale:
Maintaining the irrigation solution rate is appropriate in this situation. Pink-tinged urine in the drainage bag indicates the presence of blood, which is expected after a transurethral resection of the prostate. However, if the bleeding becomes excessive, the healthcare provider should be notified. Adjusting the irrigation solution rate might be necessary based on the provider's orders, but abruptly changing the rate without medical direction could lead to complications.
Choice B rationale:
Replacing the indwelling urinary catheter is not necessary solely based on the presence of pink-tinged urine. It is essential to assess the patient's overall condition and the extent of bleeding before considering catheter replacement. Catheter replacement without a valid reason can increase the risk of infection and discomfort for the patient.
Choice C rationale:
Performing the Credé's maneuver involves manual compression of the bladder to assist with urine elimination. This maneuver is not indicated in this situation and could potentially cause harm or disrupt the continuous bladder irrigation. It is essential to follow evidence-based practices and avoid interventions that are not appropriate for the patient's condition.
Choice D rationale:
Warming the irrigation solution is not relevant to the situation described. The presence of pink-tinged urine suggests bleeding, which requires careful monitoring and appropriate medical intervention. Warming the solution does not address the underlying cause of the bleeding and should not be the nurse's primary concern in this scenario.
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