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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- A. Incorrect. The nurse should educate the parent on the importance of nebulizer treatments to deliver medications that thin and loosen mucus in the airways.
- B. Incorrect. The nurse should advise the parent to contact the provider if the child has a fever, which could indicate an infection or inflammation in the lungs.
- C. Correct. The nurse should initiate a request for a high-frequency chest compression vest, which is a device that vibrates the chest wall and helps mobilize mucus from the lungs.
- D. Incorrect. The nurse should encourage the parent to support the child's participation in team sports, which can improve lung function and social skills.
Correct Answer is B
Explanation
- A. Chest x-ray is not correct because it is not related to valproic acid therapy or its adverse effects.
- B. Serum liver enzyme levels is correct because valproic acid can cause hepatotoxicity and liver function tests should be monitored regularly.
- C. ABGS is not correct because it is not indicated for valproic acid therapy or its adverse effects.
- D. Urine culture and sensitivity is not correct because it is not related to valproic acid therapy or its adverse effects.
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