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?
Encourage oral fluids.
Administer acetaminophen as an antipyretic.
Apply topical calamine lotion.
Initiate transmission-based precautions.
The Correct Answer is D
A. 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.
C. 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.
B. 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 ["A","B","C","D","E","F"]
Explanation
A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.
B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.
C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss.
D: Correct. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.
E: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively.
F: Correct. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.
G: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.
Correct Answer is A
Explanation
Choice A reason:
The statement is correct because chickenpox is highly contagious, and visiting someone with active chickenpox can put the pregnant individual at risk of contracting the infection. The recommendation is to avoid contact with individuals who have chickenpox, especially during pregnancy. The correct approach is to stay away from the infected person until they are no longer contagious (which is usually after all the sores have crusted over and dried up).
Choice B reason:
The statement Is incorrect because taking antibiotics for a viral infection is not appropriate, as antibiotics are only effective against bacterial infections, not viruses. Using antibiotics inappropriately can lead to antibiotic resistance and other potential side effects. Viral infections are generally managed with supportive care.
Choice C reason:
The statement is incorrect because handwashing is an essential infection prevention measure, but washing hands for 10 seconds with hot water may not be sufficient to remove germs effectively. The recommended duration for handwashing is at least 20 seconds with soap and water.
Choice D reason:
The statement is incorrect because cleaning a cat's litter box during pregnancy is not recommended due to the potential risk of exposure to the parasite Toxoplasma gondii, which is found in cat faeces. Toxoplasmosis can cause serious health issues in the developing foetus. It is best for pregnant individuals to avoid cleaning the litter box and have someone else do it or wear gloves and wash hands thoroughly afterward if no one else can do it.
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