A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?
Place an isolation cart outside of the room to initiate droplet precautions.
Schedule bedside play time with the occupational therapist.
Instruct the child's parents about the need for transmission precautions.
Assign the child to a room close to the nurse's station.
The Correct Answer is A
Choice A Reason: This is the best action because it prevents the spread of infection to other clients and staff. Mumps is a viral infection that causes inflammation of the salivary glands and can be transmitted by respiratory droplets. The nurse should place an isolation cart outside of the room and wear a mask, gloves, and gown when entering.
Choice B Reason: This is not the first priority because it does not address the risk of infection. The nurse should schedule bedside play time with the occupational therapist to promote the child's development and coping, but this can be done later.
Choice C Reason: This is not the first priority because it does not ensure that infection control measures are in place. The nurse should instruct the child's parents about the need for transmission precautions and educate them on how to care for their child at home, but this can be done later.
Choice D Reason: This is not the first priority because it does not prevent the spread of infection. The nurse should assign the child to a room close to the nurse's station to monitor his condition and provide comfort, but this is not a critical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Cautioning the nurse that one more tardiness will result in probational employment is not the best approach because it is too punitive and does not address the underlying cause of the tardiness. The nurse manager should first try to understand why the nurse is late and offer support or guidance if needed.
Choice B Reason: Offering to switch the nurse's shift assignments to afternoons or evenings is not the best approach because it may not solve the problem of tardiness and may create resentment among other staff members who have to adjust their schedules. The nurse manager should respect the nurse's preferences and availability but also hold the nurse accountable for fulfilling their responsibilities.
Choice C Reason: This is the best approach because it communicates clearly and respectfully what is expected of the nurse and why it is important for them to be punctual. The nurse manager should also provide feedback and recognition when the nurse improves their attendance.
Choice D reason: Having the nurse sign a copy of the hospital employee attendance policy is not the best approach because it may imply that the nurse is unaware or indifferent to the policy. The nurse manager should assume that the nurse knows and agrees with the policy, but may need some assistance or motivation to follow it.
Correct Answer is A
Explanation
Choice A Reason: This is the correct answer because the client's vital signs indicate that she is hypovolemic and dehydrated due to the leakage of gastric contents from the anastomosis site. The nurse should replace fluids intravenously to prevent shock and electrolyte imbalance.
Choice B Reason: Recording the amount of daily wound drainage is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should monitor the wound drainage for signs of infection and report any changes to the physician.
Choice C Reason: Assessing skin condition and turgor for breakdown is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should assess the skin for signs of dehydration and pressure ulcers and provide appropriate skin care.
Choice D Reason: Turning every 2 hours around the clock from side-to-side is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should turn the client to prevent complications such as pneumonia and atelectasis but also consider the client's comfort and pain level.

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