The home health nurse arrives at a home and finds a 9-year-old ...

[jjjetplane]

The home health nurse arrives at a home and finds a 9-year-old client who is sitting upright in the tripod position and has marked stridor. The nurse should:
 
  a. Examine the back of the throat using a tongue depressor
  b. Assist the child to lie down, and administer a dose of triamcinolone acetonide (Aristocort)
  c. Take the child to the bathroom, and turn on the hot water to create steam
  d. Arrange for transportation to the hospital

Question 2

A newborn, premature twin exhibits respiratory distress with retractions, nasal flaring, cyanosis, grunting, and fine, scattered rales. What nursing interventions would you expect the physician to order?
 
  1. Place an NG tube for feeds, monitor respiratory status on ventilator, record I& O's, start an IV, and send electrolyte panel to the laboratory and monitor temperatures
   2. Cardio- respiratory monitoring, frequent suctioning on ventilator, and monitoring blood glucose level hourly
   3. Placing infant in semi-fowler's position on affected side with head of the bed elevated, oxygen via nasal cannula, keeping NPO, and preparing parents for surgery
   4. Giving surfactant intravenously within the first 12 hours of life and repeating every 12 hours for three days.

[abro1885]

Answer to Question 1

D
This child should get to the hospital as these are signs of epiglottitis, a life-threatening emergency. The throat examination might cause laryngospasm and respiratory arrest. Steam and inhalants are of little use.

Answer to Question 2

1
Feedback
1. Place an NG tube for feeds, monitor respiratory status on ventilator, record I& O's, start an IV, and send electrolyte panel to the lab and monitor temperatures
2. A ventilator is not needed at this time. Blood glucose should be monitored because it can cause an increase in respiratory distress.
3. Surgery is not indicated at this time.
4. The statement does not indicate the level of prematurity for the infant. Surfactant is not needed at this particular time.