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 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.
Correct Answer is C
Explanation
A. While child protective services may be necessary in cases of abuse or neglect, it is premature to take this action without understanding the family's dynamics and assessing the parent’s knowledge and skills regarding asthma management.
B. Providing a detailed medication schedule and healthcare provider information is helpful but does not actively engage the parent in the child's care or education about asthma management.
C. Empowering the parent through comprehensive education will foster engagement and collaboration, equipping them with the knowledge needed to support their child's asthma management effectively at home.
D. Reviewing the asthma action plan is important, but it should involve both the child and parent to ensure that the parent is actively engaged and understands how to implement the plan.