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 ["C","D"]
Explanation
A. The child should avoid tub baths or submerging in water for several days post-procedure to reduce the risk of infection and keep the catheter site dry; sponge baths are usually recommended.
B. Keeping the child home for an entire week may be excessive; the duration of home care typically depends on the child's recovery, and many children can return to school sooner if they feel well.
C. Offering clear liquids for the first 24 hours helps ensure the child stays hydrated and allows for easier digestion following anesthesia or sedation.
D. Giving acetaminophen for discomfort is appropriate, as it can help manage any pain or discomfort the child may experience after the procedure, and is usually a recommended practice.
Correct Answer is ["A","C","D","E"]
Explanation
A. The parent applying prescribed medication as instructed indicates proper understanding of post-operative care and adherence to treatment.
B. Allowing the child to lift their older sibling above the ground is inappropriate as it can lead to increased pressure on the ear, risking complications.
C. Enforcing nose blowing only when necessary is a correct action since excessive force can displace the tympanoplasty tube or introduce bacteria into the ear.
D. Planning to have the child use ear plugs in the shower is an effective precaution to protect the ears from water exposure, which is essential post-surgery.
E. Reporting purulent drainage immediately to the surgeon shows awareness of potential complications and the need for prompt medical attention.