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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. A child with varicella (chickenpox) should return to school only after all the blisters have crusted over, indicating that the infectious stage has passed and they are no longer contagious.

B. Receiving the varicella vaccine does not apply to children who already have the infection; vaccination is preventive, not a treatment for those already infected.

C. Completing one week of antiviral medication is not a sufficient criterion for returning to school, as the child may still be contagious until all lesions are crusted.

D. Returning to school as soon as the rash appears is not safe, as the child is highly contagious during the initial rash stage and until all lesions have crusted.

Correct Answer is ["C","D","E"]

Explanation

A. Vocal changes are more pronounced in boys during puberty; girls typically do not experience significant vocal changes.

B. Height does not decrease; instead, girls experience a growth spurt during puberty before reaching their adult height.

C. Breast development is one of the first signs of puberty in girls, typically occurring between ages 8 and 13.

D. Menarche, the first menstrual period, usually occurs later in puberty and is an important milestone indicating the onset of reproductive capability.

E. Increased axillary hair growth is also a common change that occurs during puberty as hormone levels rise.

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