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 otitaining an x-ray of the child's neck
Initiate IV antibiotics.
Place the child on droplet precautions
The Correct Answer is C
A. Administer 0.9% sodium chloride IV solution.
Explanation: While maintaining hydration is essential, initiating IV fluids with normal saline can be done concurrently with the administration of antibiotics. However, the immediate priority is to start antibiotics to address the infection and prevent airway compromise.
B. Assist with obtaining an x-ray of the child's neck.
Explanation: Imaging studies, such as x-rays, may be helpful for diagnosis but are not the immediate priority in suspected epiglottitis. Delaying antibiotic administration for an x-ray could lead to a deterioration in the child's condition.
C. Initiate IV antibiotics.
Epiglottitis is a potentially life-threatening condition where the airway can rapidly become compromised due to swelling of the epiglottis. The immediate priority is to start antibiotic therapy to target the underlying infection, usually with IV antibiotics like ceftriaxone or ampicillin-sulbactam, to prevent the worsening of symptoms and complications.
D. Place the child on droplet precautions.
Explanation: Infection control measures like droplet precautions are important to prevent the spread of infection, but the primary focus initially is on addressing the immediate medical needs of the child, such as starting antibiotic therapy to manage the suspected epiglottitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I am unable to discuss this, but I can contact my supervisor to speak with you."
Explanation: While it is appropriate to involve a supervisor in difficult situations, the nurse should first clarify the legal obligation to report suspected child abuse. This response may leave the impression that the nurse is avoiding the question.
B. "As a nurse, I am required by law to report suspected child abuse."
Explanation:
Nurses are mandated reporters, meaning they are legally obligated to report suspected child abuse. It is important to communicate this legal obligation to the parents when they inquire about the reason for the report. This response is honest, direct, and reinforces the nurse's ethical and legal responsibility to prioritize the well-being and safety of the child.
C. "I reported the incident to my supervisor who decided to contact the authorities."
Explanation: This response may create confusion about the reporting process. It is important to convey that reporting is a legal obligation for the nurse, and it is not solely at the discretion of the supervisor.
D. "The provider will be coming to explain the situation."
Explanation: While involving other healthcare professionals, such as a provider, may be part of the process, it is crucial to emphasize the nurse's legal responsibility to report suspected child abuse. This response does not clearly communicate the legal obligation that the nurse has in reporting such incidents.
Correct Answer is D
Explanation
A. "Limit your caloric intake to avoid becoming overweight."
Explanation: This statement emphasizes the importance of maintaining a healthy weight through balanced nutrition and avoiding excessive caloric intake. It promotes the prevention of overweight and obesity.
B. "Tanning beds are much safer than lying in the sun."
Explanation: This statement is incorrect. Tanning beds are not safer than natural sunlight and are associated with an increased risk of skin cancer. Adolescents should be advised to protect their skin from harmful UV radiation.
C. "Share piercing needles only with close friends you trust."
Explanation: This statement is unsafe and promotes risky behavior. Sharing piercing needles can lead to the transmission of bloodborne infections such as HIV and hepatitis. The nurse should emphasize the importance of using sterile needles and avoiding risky behaviors.
D. "Your need for sleep will increase during periods of growth."
Explanation:
During periods of growth, adolescents often experience increased physical and hormonal changes, and adequate sleep is crucial for overall health and well-being. Sleep plays a vital role in growth, immune function, and cognitive performance. Adolescents should be encouraged to prioritize getting sufficient sleep for their age group.
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