The nurse in the pediatric clinic is caring for a toddler presenting with upper respiratory cold symptoms including a sore throat and fever, but no cough. The throat culture shows no growth. During discharge education, which instruction should the nurse include for the family?

Avoid lying the toddler flat on the back.

Monitor closely for drooling and agitation.

Inspect the throat for exudate.

Listen for the development of hoarseness.

Answer and Explanation

The Correct Answer is B

Brief introduction:

Acute epiglottitis is a life-threatening supraglottic inflammation typically caused by Haemophilus influenzae type b. Rapid swelling of the epiglottis can lead to total airway occlusion within minutes or hours. Classic clinical presentation includes the "four Ds": drooling, dysphagia, dysphonia, and distressed inspiratory efforts, requiring immediate medical intervention to secure a patent airway via intubation or tracheostomy.

Rationale:

A. Avoiding lying the toddler flat on the back is a general comfort measure for congestion, but it is not the priority instruction. While an upright position may help with drainage, it does not address the high-risk potential for sudden obstruction seen in pediatric respiratory emergencies. The nurse must focus on identifying signs of imminent respiratory failure.

B. Monitoring closely for drooling and agitation is the most critical instruction. These symptoms indicate that the toddler cannot swallow secretions due to severe edema and is experiencing hypoxia. Agitation is an early sign of impending obstruction, and its presence requires immediate emergency evaluation to prevent complete respiratory arrest and ensure patient safety.

C. Inspecting the throat for exudate is strictly contraindicated if epiglottitis is suspected. Any manipulation of the posterior pharynx or use of a tongue blade can trigger reflex laryngospasm, leading to immediate and total airway blockage. The nurse should instruct the family never to attempt to visualize the throat during a respiratory crisis.

D. Listening for the development of hoarseness is a common assessment for viral croup or laryngitis. However, in cases of severe supraglottic swelling, the voice is more likely to be muffled or quiet rather than hoarse. The family should prioritize watching for stridor and drooling, which are much more indicative of a life-threatening upper airway emergency.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Brief introduction:

Bisphosphonates are a class of medications (such as alendronate or zoledronic acid) used to inhibit osteoclastic bone resorption, thereby increasing bone mineral density and reducing fracture risk in postmenopausal women. However, a rare but severe adverse effect of long-term or high-dose bisphosphonate therapy is Osteonecrosis of the Jaw (ONJ). This condition is characterized by the death of jawbone tissue, typically following invasive dental work or trauma, and often presents as persistent pain, swelling, or exposed bone that fails to heal.

Rationale:

A. Reporting the jaw pain to the healthcare provider is the priority action. Because ONJ is a serious complication that can lead to permanent bone damage or the need for surgery, the HCP must be notified immediately to evaluate the client and potentially suspend the medication. Early detection is critical to preventing the progression of bone necrosis.

B. Jaw pain is not a common symptom of osteoporosis. Osteoporosis is often a "silent" disease until a fracture occurs, and it typically affects the spine, hips, or wrists. Attributing jaw pain to the underlying disease would be a dangerous clinical oversight that ignores a known medication-induced emergency.

C. Determining administration technique (e.g., staying upright for 30 minutes, taking on an empty stomach) is vital for preventing esophageal irritation, but it does not address the acute risk of jaw necrosis. While administration education is a key part of bisphosphonate therapy, it is secondary to the immediate safety risk indicated by jaw pain.

D. Advising the client to gargle with salt water is an inappropriate and ineffective intervention for bone necrosis. Saltwater gargles are used for minor oral irritations or sore throats, but they cannot treat the deep ischemic bone death associated with bisphosphonate-related ONJ. This response delays necessary medical intervention.

A. Institute contact precautions for staff and visitors. B. Monitor the client's white blood cell count. C. Send wound drainage for culture and sensitivity. D. Use standard precautions and wear a mask. E. Explain the purpose of a low bacteria diet.

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

Explanation

Vancomycin-resistant enterococci (VRE) are hardy, multidrug-resistant organisms that can survive for long periods on environmental surfaces. Because VRE is primarily spread through physical contact with the patient or contaminated items, strict infection control measures are vital to prevent horizontal transmission within the healthcare facility. Management focuses on isolating the pathogen and monitoring the systemic response to the localized venous ulcer infection.

Rationale:

A. Instituting contact precautions is the standard of care for suspected or confirmed VRE. This includes placing the client in a private room and requiring staff and visitors to wear gloves and gowns upon entry. These barriers are essential to prevent the colonization of other patients and the spread of resistant bacteria via the hands of healthcare workers.

B. Monitoring the white blood cell (WBC) count is a necessary intervention to evaluate the severity of the infection and the body's immune response. An elevated WBC count (leukocytosis) with a "left shift" indicates an active systemic struggle against the bacteria. Tracking these trends helps the nurse determine if the infection is stabilizing or progressing toward sepsis.

C. Sending wound drainage for culture and sensitivity is the definitive step in confirming the diagnosis and identifying effective antibiotics. Since the infection has already proven resistant to vancomycin, the laboratory must determine which other pharmacological agents, such as linezolid or daptomycin, remain viable treatment options for this specific strain.

D. Using only standard precautions and a mask is insufficient for VRE. While standard precautions apply to all patients, the presence of a resistant organism requires enhanced precautions. Furthermore, VRE is not typically transmitted via the respiratory route, so a mask is not the primary requirement; rather, gowns and gloves to prevent skin-to-surface contact are the priority.

E. Explaining a low-bacteria (neutropenic) diet is not indicated for this client. Low-bacteria diets are generally reserved for severely immunocompromised patients, such as those undergoing bone marrow transplants, to prevent foodborne illness. A client with a venous ulcer and VRE requires high-protein nutrition to support wound healing rather than a restricted bacterial-load diet.

View Question and Answer

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

The nurse in the pediatric clinic is caring for a toddler presenting with upper respiratory cold symptoms including a sore throat and fever, but no cough. The throat culture shows no growth. During discharge education, which instruction should the nurse include for the family?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client is taking a bisphosphonate for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is A

Explanation

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

Explanation

The nurse reviews the history and physical and assessment. Select the 3 findings that require immediate follow up by the nurse.

Patient Data The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.

Patient Data Which question(s) should the nurse ask the client? Select all that apply.

The nurse is assisting in the care of a client who is in labor. The nurse notices that when the client pushes, the fetal heart rate slowly declines for 20 seconds before returning to baseline. How should the nurse identify this alteration in fetal heart rate?

A client is admitted with hypotension, tachycardia, low urine output, and dry mucous membranes after severe vomiting and diarrhea. Laboratory results indicate dehydration. Which hormone-driven response(s) should the nurse expect? Select all that apply.

Following a cardiac catheterization, an adult client is sent to the cardiovascular unit. The nurse instructs the client to keep the affected leg immobile. Which intervention should the nurse plan to include in this client's plan of care?