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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
A. Supraventricular tachycardia (SVT) typically has identifiable P waves; the absence of P waves suggests a different condition.
B. Atrial fibrillation is characterized by an irregular rhythm, inability to identify P waves, and varying intervals. This interpretation aligns with the client's ECG findings.
C. Sinus bradycardia would show identifiable P waves and a regular rhythm with a heart rate less than 60 bpm, which does not match the provided information.
D. First-degree heart block would also show identifiable P waves and regularity in the rhythm with a prolonged PR interval, which is not indicated here.
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.