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
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Using half-strength formula might not provide enough nutrition for the infant, especially if they have failure to thrive. It's essential to provide adequate nutrition to support growth and development.
Choice B rationale:
Giving fruit juice between feedings can fill the baby's stomach with low-nutrient beverages, decreasing the intake of essential nutrients needed for growth.
Choice C rationale:
Keeping the infant in a visually stimulating environment is important for cognitive and sensory development. However, this alone will not address the underlying issue of failure to thrive, which often requires medical and nutritional interventions.
Choice D rationale:
Assigning consistent nursing staff to care for the infant promotes a stable and trusting environment for the infant. Consistency in care can enhance the infant's sense of security and facilitate bonding. Additionally, it ensures that the infant's progress or any changes in condition are closely monitored by familiar caregivers, leading to prompt interventions if needed.
Correct Answer is B
Explanation
Choice A rationale:
Avoiding vigorous activity immediately after feeding is not directly related to managing gastroesophageal reflux. The rationale behind this is that keeping the infant upright after feeding helps prevent stomach contents from flowing back into the esophagus. Gravity can help reduce reflux symptoms. Vigorous activities do not impact reflux directly.
Choice B rationale:
Holding the infant in an upright position for 30 minutes after feeding is the correct choice. This position utilizes gravity to keep stomach contents down and prevents reflux. It allows time for the food to move from the stomach to the small intestine, reducing the likelihood of reflux. This intervention is widely recommended for infants with gastroesophageal reflux.
Choice C rationale:
Enlarging the bottle's nipple opening when using thickened feedings is not a recommended practice. Thickened feedings can help reduce reflux, but changing the nipple opening size is not necessary for managing reflux symptoms. The thickness of the feeding itself can help prevent regurgitation.
Choice D rationale:
Propping the bottle during feedings is not recommended. It can lead to aspiration, where the milk can enter the infant's airways, causing respiratory issues. It's essential for the infant to be held in an upright position during feedings to prevent reflux symptoms effectively.
Choice E rationale:
Feeding the infant in a side-lying position is not recommended for infants with gastroesophageal reflux. This position can increase the risk of regurgitation and aspiration. Keeping the infant upright, as mentioned in choice B, is the preferred position to minimize reflux symptoms.
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