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 D
Explanation
A. Improved hydration is important but not directly indicative of an asthma attack improvement.
B. A barking cough is often associated with conditions like croup and does not indicate improvement in asthma symptoms.
C. Decreased temperature is not a specific indicator of improvement in asthma and may not correlate with the severity of an asthma attack.
D. Decreased stridor indicates a reduction in airway obstruction and inflammation, signifying an improvement in the child’s respiratory status during an asthma attack.
Correct Answer is C
Explanation
A. Feeding on a strict schedule may not be beneficial for an infant with heart failure, as these babies often require more frequent, smaller feedings to prevent fatigue and ensure adequate nutrition.
B. Allowing the baby to take as much time as needed can be beneficial, but it is crucial to monitor for fatigue and ensure the infant receives sufficient nutrition within a reasonable time frame.
C. Adding increased calorie supplements to each bottle is an effective strategy to help meet the increased caloric needs of an infant with heart failure, indicating an understanding of the nutritional requirements.
D. While minimizing crying can be helpful, the focus should be on the infant's needs and ensuring they are fed before they become overly distressed, rather than a strict limit on crying time.