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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Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Instructing the child to walk the bicycle through intersections promotes safety by reducing the risk of accidents. Walking the bicycle ensures better visibility to drivers and allows the child to react quickly to any unexpected situations. This instruction aligns with safe biking practices and helps prevent collisions at intersections.
Choice B rationale:
Riding the bicycle against the flow of traffic is unsafe and increases the risk of accidents. Bicyclists should always ride in the same direction as traffic, following the rules of the road. Riding against traffic confuses drivers and reduces the child's visibility, making it more likely to be involved in an accident.
Choice C rationale:
Keeping the bicycle at least 3 feet from the curb while riding in the street is a good safety practice. This distance provides a buffer zone between the child and passing vehicles, reducing the risk of sideswipe accidents. Maintaining a safe distance from the curb allows the child room to maneuver and avoids hazards like potholes or debris at the edge of the road.
Choice D rationale:
Having the child's feet 3 to 6 inches off the ground when seated on the bicycle is an appropriate guideline. The child should be able to touch the ground with their feet while sitting on the bicycle seat. This ensures stability and allows the child to stop the bicycle easily when needed, enhancing overall control and safety while riding.
Correct Answer is C
Explanation
Choice A rationale:
A blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child. While assessing vital signs, the nurse should consider the patient's age-specific parameters. In this case, the blood pressure is not indicative of hemorrhage.
Choice B rationale:
Flushing of the face might be a common postoperative finding and is not necessarily indicative of hemorrhage. It can be caused by various factors such as anesthesia or emotional states. Flushing alone is not a reliable sign of hemorrhage and should be assessed in conjunction with other symptoms.
Choice C rationale:
Continuous swallowing, especially with an increased heart rate and signs of restlessness, can be indicative of hemorrhage after a tonsillectomy and adenoidectomy. Frequent swallowing suggests the presence of blood in the mouth or throat, indicating possible bleeding at the surgical site. This finding requires immediate attention and intervention by the nurse.
Choice D rationale:
A heart rate of 54/min is below the normal range for a 5-year-old child, which typically ranges from 70 to 120 beats per minute. While bradycardia can be a concern, the more specific and immediate indication of hemorrhage in this case is continuous swallowing, which signals active bleeding from the surgical site.
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