A nurse in the emergency department is caring for a preschooler who has epiglottitis. Which of the following actions should the nurse take?
Place the child in a left lateral position.
Obtain a specimen from the child's throat for a culture.
Inspect the child's throat with a padded tongue depressor.
Initiate droplet precautions for the child.
The Correct Answer is D
A. Place the child in a left lateral position: Placing the child in a left lateral position is not the priority action for a preschooler with epiglottitis. Epiglottitis is a potentially life-threatening condition characterized by inflammation and swelling of the epiglottis, which can rapidly progress to airway obstruction. The priority is to maintain a patent airway and ensure adequate oxygenation.
B. Obtain a specimen from the child's throat for a culture: While obtaining a throat culture may be necessary to identify the causative organism and guide antibiotic therapy, it is not the immediate priority in the management of epiglottitis. Airway management and stabilization take precedence.
C. Inspect the child's throat with a padded tongue depressor: Direct visualization of the throat with a padded tongue depressor is contraindicated in a child with suspected epiglottitis. This action can trigger a gag reflex and potentially cause airway obstruction or exacerbate respiratory distress. Epiglottitis is a medical emergency, and any manipulation of the airway should be performed cautiously by experienced healthcare providers in a controlled setting.
D. Initiate droplet precautions for the child: Droplet precautions are appropriate for a child with suspected or confirmed epiglottitis due to the risk of transmission of the causative organism, usually Haemophilus influenzae type B (Hib), through respiratory droplets. However, the immediate priority is to secure the airway and provide respiratory support. Once the child's airway is stabilized, appropriate infection control measures, including droplet precautions, should be implemented to prevent the spread of infection to others.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I should place the shoulder harness above the level of my baby's shoulders."
This statement is incorrect. Placing the shoulder harness above the baby's shoulders could lead to improper restraint in the event of a crash. The harness should be positioned at or slightly below the level of the baby's shoulders to provide effective protection.
B. "I should place the car seat rear-facing until my baby is 2 years old."
This statement is correct. The American Academy of Pediatrics recommends that infants and toddlers ride in a rear-facing car seat until they are at least 2 years old or until they reach the maximum height and weight limit specified by the car seat manufacturer. This position provides optimal protection for the baby's head, neck, and spine in the event of a crash.
C. "I will place the retainer clip over my baby's abdomen."
This statement is incorrect. The retainer clip, also known as the chest clip, should be positioned at armpit level to secure the harness straps. Placing it over the baby's abdomen could result in serious injuries in the event of a crash.
D. "I should position my baby at a 30-degree angle in the car seat."
This statement is incorrect. Infants should be positioned at a 45-degree angle in their car seats. This angle helps to keep the baby's airway open and prevents the head from flopping forward, which could restrict breathing. Placing the baby at a 30-degree angle may not provide adequate support and protection.
Correct Answer is C
Explanation
A. Polyuria
Polyuria, or excessive urination, is not typically associated with intussusception. This symptom is more commonly seen in conditions affecting the kidneys or urinary tract.
B. Scaphoid abdomen
A scaphoid abdomen refers to a concave or hollowed appearance of the abdomen, which is not typically observed in intussusception. In intussusception, abdominal distension and tenderness are more common findings.
C. Gelatinous red stool
Gelatinous red stool, often described as "currant jelly" stool, is a classic manifestation of intussusception. It occurs due to the mixture of blood, mucus, and bowel contents.
D. Generalized edema
Generalized edema, or swelling throughout the body, is not a typical manifestation of intussusception. It is more commonly associated with conditions such as heart failure or kidney disease.
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