Which of the following is the most critical initial nursing action for a child suspected of epiglottitis?
Prepare for airway management.
Give racemic epinephrine.
Administer intravenous antibiotics.
Obtain a throat culture.
The Correct Answer is A
Choice A rationale
Epiglottitis is a rapidly progressive, life-threatening bacterial infection causing severe swelling of the epiglottis, potentially leading to acute, complete upper airway obstruction. The most critical initial nursing action is to minimize distress and be immediately prepared for definitive airway management (intubation or tracheostomy) by the appropriate team, as the airway can close suddenly.
Choice B rationale
Racemic epinephrine is an α-adrenergic agonist used to cause vasoconstriction and reduce subglottic edema, primarily indicated for croup. Epiglottitis involves supraglottic swelling, and while it may theoretically reduce edema, the primary risk is mechanical obstruction, making preparation for airway management the priority.
Choice C rationale
While prompt intravenous antibiotic administration is essential to treat the causative bacterium, usually Haemophilus influenzae type b, this action is secondary to securing a patent airway. A patient can die from asphyxiation much faster than from bacteremia, thus airway security must be addressed first.
Choice D rationale
Attempting to obtain a throat culture in a child with suspected epiglottitis is contraindicated. Any manipulation of the posterior pharynx or epiglottis, such as using a tongue blade or swab, can trigger laryngospasm and cause immediate, complete airway obstruction, which is a catastrophic complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Keeping the head of bed (HOB) flat is contraindicated; the HOB should be elevated to 30 degrees to promote venous return from the head via the jugular veins. This elevation is critical for lowering intracranial pressure (ICP) and improving cerebral perfusion after a traumatic brain injury.
Choice B rationale
Avoiding sedation is critical for maintaining an accurate and reliable neurological assessment, which includes the Glasgow Coma Scale (GCS). Sedative medications can mask changes in the level of consciousness, pupil reaction, and motor response, thereby delaying the detection of worsening intracranial pathology.
Choice C rationale
Maintaining SpO_2 (oxygen saturation) between 95-99% is crucial to prevent hypoxia, which causes cerebral vasodilation and dangerously increases intracranial pressure (ICP), thereby worsening the secondary brain injury. However, SpO_2 is typically maintained at ≥ 94% in general trauma.
Choice D rationale
Hypotonic fluids, such as 0.45% normal saline, are contraindicated after a traumatic brain injury as they can shift fluid into the cerebral cells. This can exacerbate cerebral edema and dangerously increase intracranial pressure (ICP), thereby worsening the patient's neurological status.
Correct Answer is D
Explanation
Choice A rationale
Administering half the dose is inappropriate and lacks a scientific basis unless ordered by the provider, as it would likely be sub-therapeutic and fail to achieve the desired effect of improving myocardial contractility and reducing heart rate. Digoxin administration should be all or none based on parameters.
Choice B rationale
The acceptable apical pulse rate for administering digoxin to an infant is typically above 90-110 beats per minute (bpm). An apical pulse of 88 bpm falls below this generally accepted cutoff, indicating potential drug toxicity or the therapeutic effect lowering the rate too much, necessitating withholding the dose.
Choice C rationale
Administering double the dose is a dangerous, unscientific action that would significantly increase the risk of digoxin toxicity, which can cause severe cardiac arrhythmias, gastrointestinal symptoms, and potential cardiac arrest, particularly in infants who are highly susceptible to small dose changes.
Choice D rationale
The normal heart rate for an infant is significantly higher than 88 bpm. Holding the dose and notifying the provider is the required action. Bradycardia in an infant receiving digoxin is the cardinal sign of potential toxicity or an excessively deep therapeutic effect, and the provider must assess the situation before further dosing.
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