A nurse is admitting a child who has suspected epiglottitis. Which of the following actions should the nurse take first?
Administer 0,9% sodium chloride IV solution.
Assist with obtaining an x-ray of the child's neck
Initiate IV antibiotics.
Place the child on droplet precautions
The Correct Answer is D
A. Administer 0.9% sodium chloride IV solution: Although IV fluids might be necessary to maintain hydration and circulation, this is not the priority over preventing the spread of infection.
B. Assist with obtaining an x-ray of the child's neck. Imaging can help confirm the diagnosis but should be done after ensuring infection control measures.
C. Initiate IV antibiotics. Antibiotics are crucial for treatment but should follow the implementation of droplet precautions to prevent the spread of infection.
D. Place the child on droplet precautions.
Epiglottitis is a medical emergency primarily caused by bacterial infections, such as Haemophilus influenzae type B (Hib). The first priority is to ensure the safety of both the patient and others by preventing the spread of infection. Placing the child on droplet precautions helps to contain the bacteria and protect healthcare workers and other patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "This shunting allows oxygenated and unoxygenated blood to mix."
Explanation: This statement is correct. In PDA, the shunting of blood between the aorta and pulmonary artery allows oxygenated and unoxygenated blood to mix, leading to decreased oxygen saturation in the systemic circulation.
B. "Blood is shunted to the right side of the heart."
Explanation: This statement is correct. In PDA, blood is shunted from the left side of the heart (aorta) to the right side of the heart (pulmonary artery).
C. "This shunting results in increased pulmonary blood flow."
Explanation: This statement is correct. PDA leads to increased pulmonary blood flow as a result of the shunting of blood from the aorta to the pulmonary artery.
D. "Blood is shunted to the left side of the heart."
Explanation:
A patent ductus arteriosus (PDA) is a congenital heart defect where the ductus arteriosus, a fetal blood vessel that normally closes shortly after birth, remains open. In PDA, blood is shunted from the aorta (left side of the heart) to the pulmonary artery (right side of the heart), resulting in increased pulmonary blood flow. Therefore, the correct statement is that "Blood is shunted to the right side of the heart."
Correct Answer is B
Explanation
A. Changes in the voice signal the beginning of puberty.
Explanation: Changes in the voice, specifically deepening, are associated with puberty, but they typically occur later in puberty. The voice change is related to the growth of the larynx (Adam's apple) and tends to happen after other physical changes.
B. Gynecomastia commonly occurs during late puberty.
Explanation:
Gynecomastia, the development of breast tissue in males, is a common occurrence during puberty. It is often temporary and tends to happen during late puberty. The enlargement of breast tissue can be a source of concern for adolescent boys, and providing information about the normalcy and temporary nature of gynecomastia can be reassuring for both parents and boys.
C. Puberty might be delayed if scrotal changes have not occurred by the age of 11 years.
Explanation: The timing of pubertal changes can vary among individuals. While certain age ranges are provided as general guidelines, the absence of scrotal changes by a specific age does not necessarily indicate delayed puberty. Puberty is a gradual process with individual variations.
D. Growth spurts in height occur toward the end of midpuberty.
Explanation: Growth spurts in height, known as the adolescent growth spurt, typically occur during midpuberty. This phase is marked by rapid growth in height, changes in body composition, and the development of secondary sexual characteristics.
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