The nurse is assessing a 5-year-old girl who is anxious, has a high fever, speaks in a whisper, and sits up with her neck thrust forward. Based on these findings, the nurse would avoid which of the following interventions?
A) Providing 100% oxygen
B) Visualizing the throat
C) Allowing the child to sit up
D) Auscultating for lung sounds
B
Response:
The child is experiencing signs and symptoms of epiglottitis, which can be life-threatening. Under no circumstances should the nurse attempt to visualize the throat. Reflex laryngospasm may occur, precipitating immediate airway occlusion. Providing 100% oxygen in the least invasive manner that is most acceptable to the child is a sound intervention, as is allowing the child to assume a position of sitting forward with the neck extended. Auscultation would reveal breath sounds consistent with an obstructed airway.
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