an nclex practice question.. wondering what you guys think

[jennifer_app]

A 3 year-old child is brought to the pediatric clinic after experiencing the sudden onset of irritability, thick muffled voice, croaking on inspiration and skin that's hot to the touch. The child sits leaning forward, tongue protruding, drooling and has suprasternal retractions. What should a nurse do first?

1) notify physician

2)collect sputum collection

3)examine throat

4) x ray of upper airways

[AmyRN303, BSN, RN]

This is one where I would prefer A. Usually, NCLEX questions try to get you not to turf to other people, but retractions, fever, and drooling sound like epiglottitis to me, which is an emergent situation. What was your answer?

[UnaNayeli]

1. I will provide my rationales if you tell me what you think.

[jennifer_app]

the answer is A... I thought it may have been to assess first :X but I was wrong.. do you guys mind providing the rationale?

[JustBeachyNurse, LPN]

Because if it is epiglotitis and you examine the throat accidentally touching or manipulating the affected area the airway can swell and you will have less than 5 minutes to perform an emergency tracheotomy. The idea in this potentially life threatening case is to call MD and get an emergency trach tray at bedside STAT. Especially in a child as their airway is much smaller and they have less reserves to compensate based on the patient description. The signs described are classic for epiglottitis.

http://www.mayoclinic.org/diseases-conditions/epiglottitis/basics/definition/con-20027854

[AmyRN303, BSN, RN]

You'd still be assessing. The question provides the assessment you have done. What this question wants you to recognize is that epiglottitis is an emergency. Because of the epiglottis swelling (the big tip off is the drooling and age of the patient) a trach may be needed immediately. This is one situation (and I found there aren't that many in NCLEX land) where you would alert the physician immediately.

[jennifer_app]

Thank you guys!!!

[JustBeachyNurse, LPN]

You do assess then notify. The option C is to examine the throat which is the key factor. You assessed the s/s and determined an emergent scenario & notify physician. You do not need to examine or visualize the throat. The physician will likely order a stat neck X-ray and have anesthesiology and/or ENT on standby with a emergency trach kit at bedside. I've seen this once in pedi and once in an adult. The muffled voice, drooling & retractions are key.