Health Promotion and Maintenance
51. Which nursing intervention should a nurse perform on a young child suspected of having a diagnosis of acute epiglottitis whose oxygen saturation measures 93% on room air?
Health Promotion and Maintenance
51. Which nursing intervention should a nurse perform on a young child suspected of having a diagnosis of acute epiglottitis whose oxygen saturation measures 93% on room air?
. Allow the child to sit in a position of comfort.
. Provide small amounts of liquid orally via a syringe.
. Inspect the child's nares to assess degree of swelling.
. Apply 100% oxygen via mask.
Test-Taking Tip
Children with epiglottitis are at risk for complete airway obstruction. Note that all but one of the answer options requires a nursing intervention near the child's nose or mouth, which may cause distress. Select the option that will not agitate the child further.
Content Area: Child Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is correct because the child with acute epiglottitis is likely to be restless and agitated due to the progressive airway obstruction. The child should be allowed to maintain a position of comfort (e.g., sitting upright) to avoid further agitation and impaired oxygenation. Answer 2 is incorrect because placing any item in the child's mouth is contraindicated with a diagnosis of acute epiglottitis because this may lead to complete airway obstruction. Answer 3 is incorrect because the inspection of the child's nares is likely to agitate the child, and is also unnecessary since the primary area of swelling is in the epiglottis and not the nares. Answer 4 is incorrect because the child is maintaining oxygenation at this time and the application of a mask on a young child is likely to create anxiety, which will decrease oxygenation.