A nurse in an emergency department is caring for a toddler who has manifestations of epiglottitis. Which of the following actions should the nurse take first?

Obtain an x-ray of the child's neck

Administer intravenous antibiotics

Initiate droplet precautions

Place intubation equipment at the bedside.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Obtaining an x-ray of the child's neck may be necessary for diagnosis, but ensuring immediate safety and infection control measures take precedence.

B. Administering intravenous antibiotics is important in the treatment of epiglottitis but is not the immediate priority.

C. Initiating droplet precautions is crucial in this case to prevent the spread of infection to others but is not as important as securing the airway.

D. Placing intubation equipment at the bedside is the first priority because epiglottitis can cause airway obstruction and respiratory distress.

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Correct Answer is C

Explanation

Rationale:

A. While osteomyelitis is a serious condition requiring treatment, receiving an IV bolus of nafcillin is not an urgent procedure compared to a neurological symptom like slurred speech.

B. Pain management is important, but a pain level of 7, while significant, does not indicate an immediate life-threatening situation.

C. Slurred speech in an adolescent with sickle cell anemia could indicate a neurological complication or a stroke, which requires immediate assessment and intervention.

D. Although the toddler with a partial-thickness burn needs care, it is not as urgent as assessing a potential neurological issue like slurred speech.

A. An 18-month-old toddler who has a heart rate of 68/min B. A school-age child who has a rectal body temperature of 37.3° C (99.1° F) C. An adolescent who has a BP of 132/82 mm Hg D. A 3-month-old infant who has a respiratory rate of 30/min

Correct Answer is A

Explanation

Rationale:

A. A toddler who has a heart rate of 68/min is likely to have bradycardia, a slow heart rate that can affect oxygen delivery. Bradycardia could be caused by hypoxia, hypothermia, or cardiac problems. The nurse should report this finding to the provider immediately.

B. This temperature is within the normal range, so it does not require reporting.

C. This blood pressure is within the normal range for an adolescent, so it does not require reporting.

D. The normal respiratory rate for a 3-month-old infant is 25 to 40/min.

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A nurse in an emergency department is caring for a toddler who has manifestations of epiglottitis. Which of the following actions should the nurse take first?

Nursing Test Bank

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