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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

Answer and Explanation

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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Correct Answer is A

Explanation

- A. This client is at risk of harming themselves by removing the IV line, which could cause bleeding, infection, or loss of medication. This is a priority issue that requires immediate intervention by the nurse.

- B. This client is experiencing a common side effect of pain medication, which can be managed by administering antiemetics, fluids, or changing the medication. This is not a life-threatening issue and can be addressed after attending to the client in choice A.

- C. This client has a chronic condition that requires regular dialysis, but they are not in acute distress at this time. They should be monitored for signs of fluid overload, electrolyte imbalance, or infection, but they are not a priority over the client in choice A.

- D. This client has a psychosocial need that should be respected and supported by the nurse, but it is not an urgent issue that requires immediate attention. The nurse can arrange for a visit from the chaplain after attending to the client in choice A.

A. Telephone number. B. Place of birth. C. Driver license number. D. Room number.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should use the client's telephone number or another unique identifier, such as a medical record number or a unique identification code, to confirm the client's identity before administering medication. Using a telephone number or a unique identifier ensures accurate identification of the client and helps prevent medication errors.

Choice B rationale:

Place of birth is not a suitable identifier for confirming a client's identity. It does not provide specific and accurate information about the individual and may not be unique to the client.

Choice C rationale:

Driver license number is not a suitable identifier for confirming a client's identity. It may not be readily available in the healthcare setting, and not all clients have a driver's license. Using this identifier could lead to identification errors.

Choice D rationale:

Room number is not a suitable identifier for confirming a client's identity. Room numbers are not unique to individual clients and can change based on hospital assignments. Relying on room numbers can lead to confusion and medication errors.

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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?

Nursing Test Bank

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