A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?
Apply topical calamine lotion.
Encourage oral fluids.
Administer acetaminophen as an antipyretic
Initiate transmission-based precautions
The Correct Answer is D
Initiate transmission-based precautions.
Rationale:
- B- Encouraging oral fluids is an important intervention for a child who has a fever, as it helps prevent dehydration and electrolyte imbalance. However, it is not the priority intervention, as it does not address the risk of infection transmission to other clients or staff.
- A - Applying topical calamine lotion may help soothe the itching and discomfort caused by the vesicles, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
- C - Administering acetaminophen as an antipyretic may help reduce the fever and provide symptomatic relief for the child, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
- D - Initiating transmission-based precautions is the priority intervention, as it protects other clients and staff from exposure to the infectious agent that causes the vesicles and fever. The nurse should wear gloves, gown, mask, and eye protection when caring for the child, and place them in a private room or cohort them with other clients who have similar symptoms.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- A. Oliguria. This is incorrect because oliguria, or decreased urine output, is a sign of fluid volume deficit, not fluid volume overload.
- B. Bradycardia. This is incorrect because bradycardia, or slow heart rate, is not a typical sign of fluid volume overload, unless the client has a cardiac condition that affects the heart's response to fluid overload.
- C. Dyspnea. This is correct because dyspnea, or difficulty breathing, is a common sign of fluid volume overload, as excess fluid accumulates in the lungs and impairs gas exchange.
- D. Poor skin turgor. This is incorrect because poor skin turgor, or decreased elasticity of the skin, is a sign of dehydration, not fluid volume overload.
Correct Answer is B
Explanation
Choice A rationale:
Assisted living facilities are suitable for individuals who need assistance with activities of daily living but do not require skilled nursing care. This option might not be necessary based on the partner's exhaustion alone.
Choice B rationale:
Respite care provides temporary relief to caregivers, allowing them to take a break from their caregiving responsibilities. Given the partner's exhaustion, respite care would offer the much-needed rest, reducing caregiver burnout and ensuring better care for the client at home.
Choice C rationale:
Rehabilitation services are designed for patients who need specialized therapy after an illness or injury. While they might be beneficial for the client following a stroke, they do not directly address the partner's exhaustion and need for relief.
Choice D rationale:
Skilled nursing facilities provide 24/7 medical care for individuals with complex medical needs. The partner's exhaustion does not necessarily indicate the need for skilled nursing care, as the client's condition and care requirements were not provided in the scenario.
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