A nurse is planning care for a toddler who has epiglottitis.
Which of the following interventions should the nurse include?
Assess the child for frequent swallowing.
Continuously monitor the child’s respiratory status.
Carefully suction the child’s oropharynx to remove secretions.
Administer pancreatic enzymes with meals.
The Correct Answer is B
This is because epiglottitis is a life-threatening condition that can cause severe airway obstruction and respiratory distress in children. The nurse should monitor the child for signs of worsening breathing, such as stridor, cyanosis, restlessness, or drooling. The nurse should also be prepared to assist with intubation or tracheostomy if needed.
Choice A is wrong because assessing the child for frequent swallowing may increase the risk of vomiting and aspiration. Swallowing may also be difficult and painful for the child due to the inflammation of the epiglottis.
Choice C is wrong because suctioning the child’s oropharynx may cause more swelling and irritation of the epiglottis, or trigger a spasm that can close off the airway. The nurse should avoid any stimulation of the throat or mouth that may worsen the condition.
Choice D is wrong because administering pancreatic enzymes with meals is not relevant to epiglottitis. Pancreatic enzymes are used to treat cystic fibrosis, a genetic disorder that affects the lungs and digestive system. Epiglottitis is caused by a bacterial infection or an injury to the throat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hematuria is the presence of red blood cells in the urine, which can make it appear pink or cola-colored. Hematuria is a common sign of glomerulonephritis, which is inflammation of the tiny filters in the kidneys (glomeruli) that remove waste and excess fluid from the blood. Hematuria occurs because the inflamed glomeruli allow some blood cells to leak into the urine.
Choice B is wrong because polyuria is the production of abnormally large amounts of urine. Polyuria is not a typical feature of acute glomerulonephritis, which may actually cause reduced urine output due to fluid retention and decreased kidney function.
Choice C is wrong because weight loss is not a common symptom of acute glomerulonephritis. On the contrary, weight gain may occur due to fluid retention and edema (swelling) in the face, hands, feet and abdomen.
Choice D is wrong because hypotension is low blood pressure. Hypotension is not usually associated with acute glomerulonephritis, which may cause high blood pressure (hypertension) due to fluid overload and impaired sodium excretion by the kidneys.
Normal ranges for blood pressure are less than 120/80 mmHg for adults. Normal ranges for urine output are about 800 to 2000 mL per day for adults.
Normal ranges for protein in the urine are less than 150 mg per day for adults. Normal ranges for red blood cells in the urine are less than 3 per high-power field for men and less than 5 per high-power field for women.
Correct Answer is A
Explanation
This statement indicates that the client understands the need to avoid activities that can increase intraocular pressure, such as lifting heavy objects, bending over, coughing, or straining. An increase in intraocular pressure can cause complications such as bleeding, inflammation, or recurrent detachment of the retina.
Choice B is wrong because sewing is a near-vision activity that can cause eye strain and fatigue. The client should avoid near-vision activities for at least two weeks after surgery.
Choice C is wrong because jogging is a vigorous exercise that can cause jarring movements and increase blood pressure. The client should avoid vigorous exercise for at least six weeks after surgery.
Choice D is wrong because bending at the waist can increase intraocular pressure and compromise the healing of the retina. The client should avoid bending at the waist for at least two weeks after surgery.
The retina is the light-sensitive layer of tissue that lines the back of the eye.
It converts light into electrical signals that are sent to the brain through the optic nerve.
A detached retina occurs when the retina separates from its underlying tissue due to a tear, hole, or break in the retina.
This can cause vision loss or blindness if not treated promptly.
The most common treatment for a detached retina is a surgery called vitrectomy. It typically involves three main steps:
- The vitreous gel inside the eye must be removed.
- A gas bubble is injected into the eye to hold the retina against its underlying tissue while allowing it to heal.
- Laser or cryotherapy creates scar tissue that helps reattach the retina.
The recovery time after retinal detachment surgery varies depending on the type and extent of the detachment, the type of surgery, and the individual healing process of the client.
Some general guidelines to follow after retinal detachment surgery are:
- Rest your eyes for at least two weeks after the surgery.
- Wear sunglasses when outdoors, as bright light may cause discomfort and strain on the eye that has been operated upon.
- If your doctor recommends, use artificial tears every few hours to keep moisture in the eye and lubricate it correctly.
- Take your medicines as directed by your doctor.
- You may use ice on your eye to reduce swelling
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