A nurse is admitting a child who has suspected epiglottitis. Which of the following actions should the nurse take first?
Administer 0.9% sodium chloride IV solution.
Place the child on droplet precautions.
Initiate IV antibiotics.
Assist with obtaining an x-ray of the child's neck.
The Correct Answer is B
A. Administering IV fluids may be necessary but is not the first priority in managing a suspected airway emergency.
B. Placing the child on droplet precautions is the first action to take to prevent the spread of infection and protect healthcare workers, given the suspected diagnosis of epiglottitis.
C. Initiating IV antibiotics is essential but should follow ensuring that appropriate precautions and assessments are in place.
D. While obtaining an x-ray can confirm the diagnosis, the child's safety and airway management must be prioritized first to avoid potential respiratory distress.
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Correct Answer is ["A","E","F"]
Explanation
A. Providing privacy during personal care and procedures is essential for adolescents, as it helps them feel more secure and respected during a vulnerable time.
B. This option is incorrect; discussing changes related to puberty can help the adolescent understand their body and promote healthy coping mechanisms.
C. Treating the adolescent as if they are not competent undermines their autonomy and can negatively impact their self-esteem; adolescents should be involved in their care and decision-making when appropriate.
D. Disregarding confidentiality can lead to a breakdown of trust; it is important to respect the adolescent's privacy while also keeping parents informed within appropriate limits.
E. Showing respect for the client's feelings and concerns helps validate their experiences and fosters a supportive environment during a challenging time.
F. Listening carefully to the client’s thoughts and concerns encourages open communication, allowing the nurse to address any worries and support the adolescent’s emotional needs.
Correct Answer is D
Explanation
A. Preparing for immediate surgery is necessary, but the priority intervention is to ensure adequate oxygenation and blood flow through the ductus arteriosus before surgery can be performed.
B. Initiating feeding through a nasogastric tube is not a priority for an infant with this condition, as their immediate need is to address the circulatory issue rather than feeding.
C. Administering oxygen via nasal cannula may provide some relief but is not sufficient as a standalone intervention for transposition of the great vessels, which requires maintaining ductal patency to allow mixing of oxygenated and deoxygenated blood.
D. Administering prostaglandin E1 (PGE1) is the priority intervention, as it helps maintain patency of the ductus arteriosus, allowing for temporary stabilization of the infant’s condition until surgical intervention can be performed.