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 A
Explanation
A. Giving pancreatic enzymes before snacks and meals is essential for children with cystic fibrosis to help with digestion and nutrient absorption due to their pancreatic insufficiency.
B. Children with CF often require increased salt intake, especially during hot weather or heavy exercise, due to higher salt losses in sweat.
C. A child with CF typically needs a high-calorie, high-fat diet to meet their energy requirements and to support growth, rather than low-fat meals with limited protein.
D. Limiting fluid intake is not recommended; children with CF often need to stay well-hydrated to help manage thick secretions and promote overall health.
Correct Answer is D
Explanation
A. Weak pulses are more indicative of reduced cardiac output or other cardiac issues, rather than specifically a large patent ductus arteriosus (PDA).
B. Cyanosis with crying can occur in various conditions, but it is not a hallmark of a large PDA; it typically presents with other symptoms.
C. Chronic hypoxemia is more associated with severe heart defects or lung conditions, whereas a large PDA may present with other signs first.
D. A systolic murmur is a classic finding in large PDAs due to the left-to-right shunting of blood, making it the most expected manifestation in this scenario.