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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is A. Uses a firm-bristled toothbrush increases the client's risk for injury because it can cause bleeding gums and oral mucosal damage in clients with pernicious anemia, who have reduced platelet count and impaired clotting. The other findings do not increase the risk for injury and may be beneficial for clients with pernicious anemia. Increased intake of green, leafy vegetables provides folic acid, which is essential for red blood cell production. Drinks 2,500 mL of fluid per day prevents dehydration and maintains blood volume. Wears a face mask around others reduces exposure to infections, which can be serious in clients with pernicious anemia, who have impaired immunity due to low white blood cell count.

A. "Using this machine increases my risk of overdose." B. "I can get pain medication any time as long as I press the button." C. "My partner can press my pain medication button for me if I am sleeping." D. "I will receive a limited amount of pain medication when I press the button." .

Correct Answer is D

Explanation

The correct answer is D.

Choice A reason: “A. Using this machine increases my risk of overdose.” This statement is incorrect because PCA pumps are designed with safety mechanisms to prevent overdose. The pump is programmed to deliver a specific dose of medication at set intervals, and it will not dispense more medication than what is prescribed by the healthcare provider.

Choice B reason: “B. I can get pain medication any time as long as I press the button.” While it is true that the patient can self-administer medication, PCA pumps have a lockout interval that prevents the machine from delivering another dose until a certain amount of time has passed, ensuring that the patient cannot receive medication too frequently.

Choice C reason: “C. My partner can press my pain medication button for me if I am sleeping.” This statement is incorrect. Only the patient should press the button on the PCA pump to ensure that the medication is administered safely and according to the patient’s current level of pain. Allowing someone else to press the button could lead to unsafe dosing.

Choice D reason: “D. I will receive a limited amount of pain medication when I press the button.” This is the correct statement. The PCA pump allows the patient to administer a controlled amount of pain medication within safe limits set by the healthcare provider. The pump is programmed to deliver a specific dose of medication, and there is a limit to the number of doses that can be administered per hour.

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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?

Nursing Test Bank

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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?