A nurse is caring for a preschooler who has epiglottitis from a streptococcal infection. Which of the following actions should the nurse take?
Attempt to obtain a throat culture.
Use a tongue depressor to observe the back of the throat.
Apply humidified oxygen via a mask.
Initiate airborne precautions.
The Correct Answer is C
A. Attempt to obtain a throat culture: This is contraindicated because manipulating the throat could exacerbate airway obstruction, leading to a potential respiratory emergency.
B. Use a tongue depressor to observe the back of the throat: This can provoke a spasm or cause complete airway obstruction in a child with epiglottitis and should be avoided.
C. Apply humidified oxygen via a mask: This helps to keep the airways moist and can provide some relief and improve oxygenation while minimizing the risk of airway manipulation.
D. Initiate airborne precautions: Epiglottitis primarily requires droplet precautions, not airborne. Airborne precautions are used for diseases like tuberculosis, which are spread through smaller droplets that remain suspended in the air.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Restrain the toddler for 1 hr after the procedure: This is not necessary; the child should be monitored but not restrained.
B. Place the toddler in a side-lying, knee-chest position: This position helps to open the spaces between vertebrae, facilitating the lumbar puncture.
C. Ask another nurse to assist with holding the toddler in a prone position: The prone position is not appropriate for a lumbar puncture as it does not provide proper spinal alignment.
D. Swaddle the toddler in a warm blanket: While comforting, it is not relevant to the procedure itself.
Correct Answer is B
Explanation
A. Brisk pupillary reaction to light: A brisk pupillary reaction to light is a normal neurological finding and does not indicate increased ICP. Increased ICP might present with a sluggish or unequal pupil response.
B. Irritability: Irritability is a common early sign of increased ICP in infants. Changes in behaviour, such as increased irritability or lethargy, can indicate a neurological problem, including increased pressure within the skull.
C. Tachycardia: Tachycardia (increased heart rate) is not a typical indicator of increased ICP. Bradycardia (decreased heart rate) is more commonly associated with increased ICP due to the pressure on the brainstem affecting autonomic functions.
D. Increased sensory response to painful stimuli: Increased sensory response is not typically indicative of increased ICP. In fact, as ICP worsens, a decrease in sensory response or altered level of consciousness is more likely.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.