A new nurse in the emergency department is examining a 4-year-old child who is sitting upright, is drooling, and is restless. Which action by the new nurse causes an experienced nurse to intervene?
A.
Attaches a cardiac monitor and oximeter
B.
Attempts to assess throat with a tongue blade
C.
Permits child to remain in an upright position
D.
Prepares to administer racemic epinephrine (MicroNefrin)
ANS: B
This child has manifestations of acute epiglottitis. The nurse should not look into the child's throat, as this may precipitate laryngeal spasm and total airway obstruction. The experienced nurse should intervene if the new nurse attempts to do so. The other interventions are appropriate.
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