A nurse is caring for a child who has epiglottitis due to an infection with Haemophilus influenzae type B. Which of the following actions should the nurse take? Select all that apply.
Inspect the epiglottis.
Obtain a throat culture.
Monitor oxygen saturation.
Begin droplet precautions.
Initiate IV access.
Correct Answer : C,D,E
A. Inspecting the epiglottis is contraindicated in suspected cases of epiglottitis as it may trigger laryngospasm and compromise the airway.
B. Obtaining a throat culture may be indicated to confirm the presence of Haemophilus influenzae type B but is not an immediate priority in the management of epiglottitis.
C. Monitoring oxygen saturation is crucial as respiratory distress and hypoxia are common complications of epiglottitis.
D. Beginning droplet precautions is important to prevent the spread of the infectious agent to others.
E. Initiating IV access is necessary for administering fluids and medications, as well as for potential airway management in severe cases of epiglottitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Daily weight monitoring is essential in managing nephrotic syndrome to assess for fluid retention and response to treatment.
B. Positioning the child supine at bedtime is not specific to the management of nephrotic syndrome.
C. Calorie intake may need to be increased rather than limited in nephrotic syndrome to compensate for protein loss and meet increased energy needs.
D. Fluid intake may need to be restricted rather than increased, depending on the child's fluid status and response to treatment.
Correct Answer is A
Explanation
A. Discarding the first voided specimen is necessary to ensure accuracy in a 24-hour urine collection. This helps eliminate any urine that has been in the bladder prior to the start of the collection period.
B. Voiding every hour is not necessary for a 24-hour urine collection. The goal is to collect all urine produced over a 24-hour period, not voiding at set intervals.
C. Cleansing the perineum with a povidone-iodine solution prior to voiding is not typically necessary for a 24-hour urine collection unless specifically instructed by the healthcare provider.
D. Saving the final specimen in a separate container is not necessary for a 24-hour urine collection. All urine produced during the specified collection period should be saved in the same container.
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