A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take

Obtain a throat culture.

Visualize the epiglottis with a tongue depressor

Place the child in an upright position

Transport the child to radiology for a throat x-ray

Answer and Explanation

The Correct Answer is C

A. Obtaining a throat culture and B. visualizing the epiglottis with a tongue depressor are not safe actions for the nurse to perform without appropriate medical equipment and expertise. These actions can trigger a sudden airway obstruction in a child with epiglottitis. The priority is to ensure airway patency and seek immediate medical assistance.

C. Place the child in an upright position.

Suspected epiglottitis is a medical emergency that can result in rapid airway obstruction. Placing the child in an upright position helps improve airflow by allowing the throat to open and reduces the risk of complete airway obstruction. It's important not to perform invasive procedures (such as throat culture or visualization of the epiglottis) without proper medical equipment and expertise, as these actions can lead to worsening airway obstruction.

D. Transporting the child to radiology for a throat x-ray is not appropriate in this situation, as it may delay necessary interventions to secure the airway.

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Correct Answer is D

Explanation

A. Checking urine for glucose and protein is not directly related to the care of a child with a VP shunt. The focus is on monitoring the child for signs of complications related to the shunt.

B. Administering narcotics for pain control may be indicated if the child is in pain, but it is not the primary action and should be determined based on the child's pain assessment.

C. Testing cerebrospinal (CSF) fluid leakage for protein is not typically a nursing responsibility in the immediate postoperative period. Leakage of CSF should be reported to the healthcare provider, and diagnostic tests would be conducted by medical staff as needed.

D. Monitor for increased temperature.

Monitoring for an increased temperature is essential because postoperative fever could be an early sign of infection or complications related to the VP shunt. Infection and shunt malfunction are potential risks in the postoperative period.

A. Shunted past the pulmonary circulation, causing pulmonary hypoxia B. Circulated through the lungs again, causing pulmonary circulatory congestion C. Circulated through the ductus from the pulmonary artery to the aorta bypassing the left side of me heart D. Shunted past cardiac arteries, causing myocardial hypoxia

Correct Answer is C

Explanation

A. Shunted past the pulmonary circulation, causing pulmonary hypoxia: This option is not the primary reason for dyspnea in PDA. While there is shunting, it doesn't directly cause pulmonary hypoxia.

B. Circulated through the lungs again, causing pulmonary circulatory congestion: This option is partially correct but does not address the primary reason for dyspnea, which is the bypassing of the left side of the heart.

C. Circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the heart.

In patent ductus arteriosus (PDA), a fetal blood vessel called the ductus arteriosus fails to close after birth. This allows oxygenated blood from the left atrium to be shunted directly from the aorta to the pulmonary artery, bypassing the normal route through the left side of the heart and into the systemic circulation. The shunting of oxygenated blood back into the pulmonary circulation can lead to increased pulmonary blood flow and circulatory congestion, causing symptoms such as dyspnea.

D. Shunted past cardiac arteries, causing myocardial hypoxia: PDA primarily affects the pulmonary circulation and left side of the heart, not the coronary arteries. Myocardial hypoxia is not the primary mechanism of dyspnea in PDA.

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A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take

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