A nurse is admitting a child who has acute epiglottitis.
Which of the following actions should the nurse take?
Check oxygen saturation every 4 hr.
Obtain a throat culture.
Assist the child into supine position.
Initiate droplet isolation precautions.
The Correct Answer is D
Choice A rationale:
Checking oxygen saturation every 4 hours is a monitoring parameter for patients with respiratory issues but is not the priority in a child with acute epiglottitis. Airway management and infection control are more critical in this situation.
Choice B rationale:
Obtaining a throat culture is important to confirm the diagnosis of epiglottitis. However, initiating isolation precautions and ensuring the child's airway is secure take precedence in the immediate care of a child with acute epiglottitis.
Choice C rationale:
Assisting the child into a supine position is contraindicated in acute epiglottitis. This position can further compromise the airway by obstructing it. The child should be allowed to sit in a position of comfort, usually sitting upright and leaning slightly forward.
Choice D rationale:
Initiating droplet isolation precautions is crucial when dealing with a suspected or confirmed case of epiglottitis. Epiglottitis is highly contagious and is transmitted via respiratory droplets. Isolation precautions help prevent the spread of the infection to others.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Choice A rationale:
The sleeping pattern is mentioned, but it does not provide relevant information regarding the infant's condition. The fact that the infant is sleeping through the night does not address the concerns related to gastroesophageal reflux.
Choice B rationale:
Irritability is mentioned in the initial notes, indicating the infant's discomfort. However, in the follow-up visit, there is no mention of irritability, suggesting an improvement in this symptom. Monitoring irritability is essential to assess the effectiveness of interventions for gastroesophageal reflux.
Choice C rationale:
Weight is mentioned in both the initial and follow-up notes. While monitoring weight is essential, there is no indication of weight loss or inadequate weight gain in the follow-up, suggesting that the infant's nutritional status is stable.
Choice D rationale:
Regurgitation is one of the main symptoms of gastroesophageal reflux. Monitoring the frequency and severity of regurgitation is essential to assess the effectiveness of interventions, such as thickened feedings. The persistence of regurgitation in this case indicates that the condition has not completely resolved.
Choice E rationale:
Heart rate is not mentioned in the provided information, and it does not provide relevant information about the infant's condition in this context.
Choice F rationale:
Bottle feeding is mentioned, specifically the thickening of feedings. This information is crucial in assessing the effectiveness of interventions for gastroesophageal reflux. Thickened feedings are often recommended to reduce regurgitation, and the fact that the parents have been thickening the feedings suggests an attempt to manage the condition.
Correct Answer is C
Explanation
Choice A rationale:
Allowing the child to adjust their bedtime might promote autonomy, but in a hospital setting, routine and familiarity are essential for reducing anxiety in school-age children. Disrupting their home sleep routine may increase stress and hinder the child's ability to rest properly.
Choice B rationale:
Leaving the lights on in the child's room contradicts the principles of creating a sleep-conducive environment. Adequate sleep hygiene involves a dark and quiet room. Leaving lights on could interfere with the child's ability to fall asleep, potentially leading to sleep disturbances and increased anxiety.
Choice C rationale:
Following the child's home sleep routine is the most appropriate intervention. Maintaining consistency with the child's usual bedtime routine provides a sense of familiarity and security, reducing anxiety and promoting better sleep. This approach aligns with the principles of pediatric nursing, ensuring the child's emotional well-being while in the hospital.
Choice D rationale:
Providing the child with video games prior to bedtime is not recommended, especially in a hospital setting. Screen time, especially before sleep, can disrupt sleep patterns due to the blue light emitted by electronic devices. Additionally, video games may stimulate the child, making it harder for them to relax and fall asleep. This choice can exacerbate the child's stress and hinder their ability to achieve adequate sleep.
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