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. A stool fat content analysis can suggest malabsorption issues but does not specifically confirm cystic fibrosis.
B. The sweat chloride test measures the amount of chloride in the sweat, with elevated levels confirming a diagnosis of cystic fibrosis.
C. Pulmonary function tests assess lung function but are not definitive for diagnosing cystic fibrosis.
D. A sputum culture can identify respiratory infections but is not specific for cystic fibrosis diagnosis.
Correct Answer is B
Explanation
A. Doubling the dose if a dose is missed can increase the risk of bleeding and is not recommended for warfarin. Instead, the client should take the missed dose as soon as remembered unless it's almost time for the next dose.
B. Using an electric razor is recommended to minimize the risk of cuts and bleeding, which is particularly important for clients on anticoagulants like warfarin.
C. While increasing fiber intake can be beneficial for overall health, it is not specifically necessary for addressing constipation related to warfarin therapy.
D. While mild nosebleeds may occur, they are not typically common during initial treatment. Clients should be informed to report any unusual or severe bleeding.