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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. By age 6, while children can dress themselves, they may still need assistance with more complex grooming tasks, making this statement too absolute.
B. Counting backwards from 20 to 1 is typically expected by age 8, not age 7, indicating this statement is inaccurate regarding cognitive development.
C. Engaging in motor activities that require balance, such as jumping rope, is appropriate for children around age 6, demonstrating the expected physical development in this age group.
D. While children can use simple tools, mastery and effective use of tools like a screwdriver or hammer are more typical around ages 8 to 10, making this statement premature for age 6.
Correct Answer is D
Explanation
A. Weak pulses are more indicative of reduced cardiac output or other cardiac issues, rather than specifically a large patent ductus arteriosus (PDA).
B. Cyanosis with crying can occur in various conditions, but it is not a hallmark of a large PDA; it typically presents with other symptoms.
C. Chronic hypoxemia is more associated with severe heart defects or lung conditions, whereas a large PDA may present with other signs first.
D. A systolic murmur is a classic finding in large PDAs due to the left-to-right shunting of blood, making it the most expected manifestation in this scenario.
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