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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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Correct Answer is D

Explanation

A. Avoiding all oily foods is not necessary, as dietary factors have varying effects on acne; instead, moderation is key.

B. Popping pimples can lead to scarring, infection, and further inflammation, making this an inappropriate recommendation for acne management.

C. Using strong astringents can irritate the skin and worsen acne; gentle skin care is more effective for maintaining healthy skin.

D. Washing the face with a gentle cleanser twice a day helps to remove excess oil and dirt without irritating the skin, which is the most appropriate recommendation for managing acne during puberty.

Correct Answer is C

Explanation

A. Taking ferrous sulfate between meals may actually help reduce the risk of constipation, but this is not the primary reason for timing.

B. Taking the medication with food does not typically increase the risk of esophagitis; rather, it can decrease the absorption of iron.

C. Taking ferrous sulfate between meals allows for optimal absorption of iron, as food can interfere with its absorption. This response accurately explains the rationale for the timing of the medication.

D. While it is true that some patients may experience nausea when taking iron supplements with food, the primary reason for taking it between meals is to enhance absorption rather than to prevent nausea.

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