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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 ["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.

Correct Answer is B

Explanation

A. This statement is incorrect; the spacer does not primarily increase medication delivery to the oropharynx.

B. The spacer helps to increase the amount of medication that reaches the lungs by allowing larger particles to settle out and preventing them from being deposited in the mouth and throat.

C. Inhaling slowly and deeply is recommended for effective medication delivery when using an MDI with a spacer.

D. Covering the exhalation slots would prevent proper airflow and could cause the child to inhale exhaled air, which is not recommended during inhalation.

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