A nurse is assisting with the care of a preschooler who has epiglottitis. Which of the following actions should the nurse take?
Request an x-ray of the neck.
Monitor urine for protein.
Obtain a nasopharyngeal swab
Administer fluconazole.
The Correct Answer is A
A) Request an x-ray of the neck: In cases of suspected epiglottitis, a lateral neck x-ray can help confirm the diagnosis by showing the classic "thumbprint sign," which indicates swelling of the epiglottis. This is a critical diagnostic step, but it should only be performed in a controlled setting where the child’s airway can be monitored closely. The priority is to avoid any procedures that may cause irritation or further compromise the airway.
B) Monitor urine for protein: Monitoring urine for protein is not relevant to the management of epiglottitis. This condition is related to inflammation and obstruction of the upper airway, and the focus should be on respiratory management rather than renal function.
C) Obtain a nasopharyngeal swab: While obtaining a nasopharyngeal swab can help identify the organism causing an infection (often bacterial), it is not the immediate priority in a child with suspected epiglottitis. The child’s airway is the most critical concern, and diagnostic interventions that could potentially cause further distress or obstruction (such as swabbing) should be avoided until airway management is stable.
D) Administer fluconazole: Fluconazole is an antifungal medication, and its use is not appropriate for epiglottitis. Epiglottitis is most often caused by a bacterial infection, particularly Haemophilus influenzae type b (Hib), which requires antibiotic therapy, not antifungals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Condition: Opioid intoxication – The client's presentation of unresponsiveness, respiratory depression (RR 10/min), and miosis (pinpoint pupils) is consistent with opioid intoxication. Additionally, the presence of a needle in the antecubital space suggests recent intravenous drug use.
Finding: Pupil characteristics – Opioid intoxication commonly causes miosis (pinpoint pupils), which was observed in the client.
Correct Answer is C
Explanation
A) Decreased hemoglobin level: A decreased hemoglobin level is not an expected or desirable outcome of taking furosemide. While furosemide can cause fluid loss, it does not directly affect red blood cell production or hemoglobin levels. A decrease in hemoglobin could indicate anemia or another underlying issue, which should be addressed separately.
B) Increased weight of 0.91 kg (2 lb): An increase in weight, especially in a client with heart failure, could indicate fluid retention rather than effective diuresis. Furosemide is a diuretic that helps reduce fluid buildup, so an increase in weight would typically suggest that the medication is not effectively managing fluid overload, which is a key issue in heart failure.
C) Increased urinary output: An increase in urinary output is a clear indicator that furosemide is working effectively. Furosemide is a loop diuretic, which promotes the excretion of sodium and water, leading to increased urine output. This helps reduce fluid volume in the body, which is beneficial for a client with heart failure.
D) Decreased BUN level: While furosemide can affect kidney function, a decrease in blood urea nitrogen (BUN) level is not a direct indicator of the medication’s effectiveness. BUN can be influenced by various factors such as hydration status, kidney function, and protein intake. A decreased BUN level does not directly correlate with furosemide's effectiveness in treating heart failure.
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