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A nurse is caring for a pre-school age child who has epiglottitis and presents with a high fever, drooling, and a muffled voice. Which of the following actions should the nurse take?

A.

Use a tongue depressor to observe the epiglottis.

B.

Initiate airborne precautions.

C.

Monitor oxygen saturation.

D.

Obtain a throat culture.

Answer and Explanation

The Correct Answer is C

A. Using a tongue depressor can provoke spasm of the epiglottis and lead to airway obstruction; therefore, this action is contraindicated in a child with epiglottitis.  

 

B. Airborne precautions are not necessary for epiglottitis; droplet precautions are more appropriate due to the risk of transmission.  

 

C. Monitoring oxygen saturation is critical in this situation to assess the child's respiratory status and ensure adequate oxygenation, making it the most appropriate action.  

 

D. Obtaining a throat culture may not be safe or practical in this scenario, as it can provoke further distress and complications; immediate assessment and stabilization are prioritized.  


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View Related questions

Correct Answer is A

Explanation

A. Avoiding triggers that cause an asthma attack is crucial in managing asthma effectively and should be emphasized in education.

B. Cromolyn sodium is a preventive medication and should be taken regularly, not just at the first sign of difficulty; immediate relief medications are preferred during an attack.

C. The peak expiratory flow meter should be used daily to monitor asthma control, rather than just once a week.

D. It is generally not necessary for the child to stop playing sports; many children with asthma can participate in activities like basketball as long as their condition is well-managed.

Correct Answer is A

Explanation

A. Furosemide is a loop diuretic that can cause potassium loss; therefore, it is essential for the child to eat potassium-rich foods to prevent hypokalemia.

B. Taking furosemide at bedtime is not advisable due to the increased risk of nocturia and sleep disturbances from frequent urination.

C. Aspirin is not recommended without medical guidance, especially for children, as it can increase the risk of Reye's syndrome.

D. Expecting swelling in the hands and feet contradicts the purpose of furosemide, which is to reduce fluid overload; parents should report any unexpected swelling to the healthcare provider.

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