RN Comprehensive Online Practice 2023 B with complete solutions

A nurse is caring for a 5-year-old child Physical Examination: 1510: Upon visual inspection, throat is inflamed, tonsils appear pink, reddened and epiglottis is edematous and cherry red in appearance. Skin appears pale. Stridor noted upon inspiration with diminished bilateral lung sounds. Nurse's Notes: 1500 Child accompanied to emergency department by caregiver. Caregiver states child has a sore throat and reports the child has "pain on swallowing" and denies cough. Child is agitated and lean - correct answers Condition: Epiglottis Actions: Initiate droplet precautions and request a prescription for IV antibiotics Monitors: Breath sounds and temperature The nurse should anticipate initiating droplet precautions and requesting a prescription for IV antibiotics. The child is most likely experiencing epiglottis because of the clinical manifestations of a high fever, inflammation and redness of the throat, pale skin, stridor with inspiration, painful swallowing, no cough, is sitting in tripod position, and drooling. The nurse should monitor the child's temperature and breath sounds. A nurse is caring for a client who is on the spinal cord injury (SCI) unit Nurses' Notes Day 3, 1700 Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale, and dry to touch. Respirations easy and unlabored. Lung sounds diminished in lower lobes. Abdomen soft and nondistended with active bowel sounds. Client passed a small amount of hard formed stool