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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Unopened bottles of formula are not typically a source of healthcare-associated infection.
B. Bedside computer keyboards can harbor various pathogens and are commonly touched by multiple individuals without thorough cleaning, making them a common source of healthcare-associated infections.
C. Disposable diapers, if properly disposed of and not reused, are not typically a source of healthcare-associated infection.
D. Protective plastic gowns, if used appropriately, are not typically a source of healthcare-associated infection.

A. Assess both eyes together first, then each eye separately. B. Position the child 4.6 meters (15 feet) from the chart. C. Test the child without glasses before testing with glasses. D. Use a tumbling E chart for the assessment.

Correct Answer is D

Explanation

A. Assessing both eyes together first, then separately, is not a typical method for assessing visual acuity in children.
B. Positioning the child 4.6 meters (15 feet) from the chart is not practical for testing visual acuity in a clinical setting.
C. Testing the child without glasses before testing with glasses may be appropriate but is not specifically related to the method of visual acuity assessment.
D. Using a tumbling E chart is appropriate for assessing visual acuity in young children who may not recognize letters. The tumbling E chart uses a series of "E" shapes facing different directions, allowing the child to indicate the direction the "E" is facing, thus assessing visual acuity.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is D

Explanation

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