The nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this observation as indicating which finding?

Extreme fatigue

An airway obstruction

The presence of dehydration

The presence of pain

Answer and Explanation

The Correct Answer is B

B. Leaning forward with the chin thrust out, often described as the "sniffing position," is a classic sign of airway obstruction, particularly in cases of epiglottitis. This positioning helps to maximize airway patency by opening the airway and reducing the risk of further obstruction.

A. Leaning forward with the chin thrust out is not typically associated with extreme fatigue. Instead, it is a specific positioning often seen in individuals with epiglottitis to help alleviate airway obstruction and facilitate breathing.

C. Leaning forward with the chin thrust out is not indicative of dehydration. Dehydration may present with other signs and symptoms such as dry mucous membranes, decreased urine output, sunken fontanelle (in infants), and poor skin turgor.

D. Pain may be present in a child with epiglottitis but leaning forward with the chin thrust out is not primarily indicative of pain. This positioning is primarily a compensatory mechanism to alleviate airway obstruction rather than a response to pain.

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Correct Answer is D

Explanation

D. Place resuscitation equipment at the child's bedside. This is because epiglottitis can lead to a life- threatening emergency requiring immediate intervention, and having resuscitation equipment readily available is essential for rapid response.

A. Establishing intravenous access may be necessary for administering fluids and medications but it is not the nurse's priority action when caring for a child with suspected epiglottitis.

B. Droplet precautions help reduce the risk of transmission of respiratory pathogens to others. However, the priority is to address the child's respiratory distress and potential airway compromise.

C. Providing blow-by humidified oxygen can be beneficial in managing the child's respiratory status. However, securing the airway takes precedence over other interventions, as indicated by the guidelines for managing epiglottitis.

A. Providing humidified oxygen B. Monitoring respiratory rate and oxygen C. Restricting fluid intake D. Administering antibiotics E. Initiating chest physiotherapy

Correct Answer is ["A","B"]

Explanation

A. Humidified oxygen can help improve oxygenation and relieve respiratory distress by maintaining optimal humidity levels in the airways, which can be beneficial, especially in infants with bronchiolitis who may have increased respiratory secretions and airway inflammation.

B. Monitoring respiratory rate and oxygen saturation allows for early detection of respiratory distress and hypoxemia, which are common complications of bronchiolitis. Regular assessment helps guide interventions and ensures timely escalation of care if needed.

C. Restricting fluid intake is not typically indicated for children with bronchiolitis. In fact, maintaining adequate hydration is crucial for children with respiratory illnesses to help thin respiratory secretions and prevent dehydration.

D. Antibiotics are not routinely indicated for the treatment of bronchiolitis caused by viral pathogens. Bronchiolitis is typically caused by respiratory syncytial virus (RSV) or other viral infections, for which antibiotics are ineffective.

E. Chest physiotherapy is not routinely recommended for the management of bronchiolitis in infants and children. Bronchiolitis is primarily managed with supportive care measures such as humidified oxygen, hydration, and monitoring for respiratory distress.

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The nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this observation as indicating which finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a preschool-aged child who presents with manifestations of epiglottitis. Which of the following actions is the nurse's priority to perform?

Correct Answer is D

Explanation

Which of the following interventions are appropriate for nursing care of a child with bronchiolitis? (Select All that Apply.)

Correct Answer is ["A","B"]

Explanation

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