A nurse is caring for a pre-school age child who has epiglottitis and presents with a high fever, drooling, and a muffled voice. Which of the following actions should the nurse take?
Use a tongue depressor to observe the epiglottis.
Initiate airborne precautions.
Monitor oxygen saturation.
Obtain a throat culture.
The Correct Answer is C
A. Using a tongue depressor can provoke spasm of the epiglottis and lead to airway obstruction; therefore, this action is contraindicated in a child with epiglottitis.
B. Airborne precautions are not necessary for epiglottitis; droplet precautions are more appropriate due to the risk of transmission.
C. Monitoring oxygen saturation is critical in this situation to assess the child's respiratory status and ensure adequate oxygenation, making it the most appropriate action.
D. Obtaining a throat culture may not be safe or practical in this scenario, as it can provoke further distress and complications; immediate assessment and stabilization are prioritized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This option is incorrect as it does not describe the expected blood pressure difference in coarctation of the aorta.
B. Coarctation of the aorta typically presents with higher blood pressure in the upper body (arms) and lower blood pressure in the lower body (legs) due to the obstruction of blood flow distal to the aortic arch.
C. This option is incorrect because while coarctation can lead to decreased perfusion in the lower extremities, it does not typically result in decreased blood pressure in both the arms and legs simultaneously.
D. While increased blood pressure may occur in the arms, the legs would not typically show increased blood pressure in cases of coarctation.
Correct Answer is C
Explanation
A. Taking ferrous sulfate between meals may actually help reduce the risk of constipation, but this is not the primary reason for timing.
B. Taking the medication with food does not typically increase the risk of esophagitis; rather, it can decrease the absorption of iron.
C. Taking ferrous sulfate between meals allows for optimal absorption of iron, as food can interfere with its absorption. This response accurately explains the rationale for the timing of the medication.
D. While it is true that some patients may experience nausea when taking iron supplements with food, the primary reason for taking it between meals is to enhance absorption rather than to prevent nausea.
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