nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take?
Visualize the epiglottis with a tongue depressor.
Transport the child to radiology for a throat x-ray.
Obtain a throat culture.
Place the child in an upright position.
The Correct Answer is D
A. Visualizing the epiglottis with a tongue depressor is contraindicated in suspected epiglottitis due to the risk of triggering airway obstruction.
B. Transporting the child to radiology for a throat x-ray is not a priority and can delay necessary interventions.
C. Obtaining a throat culture is not appropriate in this situation, as airway compromise can occur quickly, and immediate management is crucial.
D. Placing the child in an upright position helps ease breathing and can alleviate distress, which is vital for a child with suspected epiglottitis.
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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.
Correct Answer is C
Explanation
A. Bradycardia is not typically expected in toddlers with heart failure; instead, tachycardia (increased heart rate) is more common as the body compensates for decreased cardiac output.
B. Weight loss is generally not a typical finding in toddlers with heart failure; rather, they often experience weight gain due to fluid retention.
C. Orthopnea, or difficulty breathing when lying flat, is a common symptom of heart failure and would be expected in a toddler due to fluid overload affecting respiratory function.
D. Increased urine output is usually not expected in heart failure; rather, fluid retention often leads to decreased urine output as the kidneys respond to the body's fluid balance needs.