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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. Avoiding triggers that cause an asthma attack is crucial in managing asthma effectively and should be emphasized in education.

B. Cromolyn sodium is a preventive medication and should be taken regularly, not just at the first sign of difficulty; immediate relief medications are preferred during an attack.

C. The peak expiratory flow meter should be used daily to monitor asthma control, rather than just once a week.

D. It is generally not necessary for the child to stop playing sports; many children with asthma can participate in activities like basketball as long as their condition is well-managed.

Correct Answer is D

Explanation

A. The ASO titer does not measure therapeutic levels of aminoglycosides; this response is incorrect.

B. The ASO titer is not a direct diagnostic test for rheumatic fever but indicates a recent infection with streptococcal bacteria, which can lead to rheumatic fever.

C. The test does not confirm immunity but rather measures antibodies against streptolysin O, indicating recent infection.

D. An elevated ASO titer confirms that the child had a recent streptococcal infection, which is important in diagnosing rheumatic fever.

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