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?
Use a tongue depressor to observe the epiglottis.
Initiate airborne precautions.
Monitor oxygen saturation.
Obtain a throat culture.
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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Correct Answer is B
Explanation
A. Tricuspid atresia typically leads to decreased pulmonary blood flow due to the absence of normal blood flow to the lungs.
B. Patent ductus arteriosus results in increased pulmonary blood flow because it allows blood to flow from the aorta to the pulmonary artery, increasing the volume of blood going to the lungs.
C. Coarctation of the aorta can cause decreased blood flow to the lower body, which may not directly relate to increased pulmonary blood flow.
D. Tetralogy of Fallot is characterized by decreased pulmonary blood flow due to right ventricular outflow obstruction, making it not associated with increased pulmonary blood flow.
Correct Answer is ["C","D","E"]
Explanation
A. Pertussis, or whooping cough, primarily affects the respiratory tract, particularly the trachea and bronchi, not just the nostrils.
B. Pertussis is caused by the bacterium Bordetella pertussis, making this statement incorrect as the infection is bacterial, not viral.
C. The toxins released by Bordetella pertussis damage the cilia of epithelial cells in the respiratory tract, leading to difficulty in clearing secretions.
D. The inflammation of the lungs and airways is a characteristic response to the infection, contributing to the symptoms of coughing and difficulty breathing.
E. The production of thick, mucus secretions is a hallmark of pertussis, which makes it challenging for the child to expel them, leading to severe coughing fits.