Page 58 - Saunders Comprehensive Review For NCLEX-RN

4. Maintain the child in a supine position.

5. Obtain a pediatric-size tracheostomy tray.

6. Place the child on an oxygen saturation monitor.

In a multiple-response question, you will be asked to select or check all of the
options, such as interventions, that relate to the information in the question. Focus
on the subject, interventions for the child with suspected acute epiglottitis. To
answer this question, recall that acute epiglottitis is a serious obstructive
inflammatory process that requires immediate intervention and that airway patency
is a priority. Auscultating lung sounds allows the nurse to obtain information about
airway patency without causing further airway compromise by examining the
throat. Examination of the throat with a tongue depressor or attempting to obtain a
throat culture is contraindicated because the examination can precipitate further
obstruction. A lateral neck and chest x-ray is obtained to determine the degree of
obstruction, if present. To reduce respiratory distress, the child should sit upright.
The child is placed on an oxygen saturation monitor to monitor oxygenation status.
Tracheostomy and intubation may be necessary if respiratory distress is severe.
Remember to follow the specific directions given on the computer screen.

Ordered-Response Questions

In this type of question, you will be asked to use the computer mouse to drag and
drop your nursing actions in order of priority. Information will be presented in a
question and, based on the data, you need to determine what you will do first,
second, third, and so forth. The unordered options will be located in boxes on the left
side of the screen, and you need to move all options in order of priority to ordered-
response boxes to the right side of the screen. Specific directions for moving the
options are provided with the question. See Figure 1-1 for an example. These type of
practice questions are located on the accompanying Evolve site.

58