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 D
Explanation
A: Incorrect. Hospital-based hospice care is not a service provided by PACE, which is a program that offers comprehensive medical and social services to eligible older adults who wish to remain in their own homes and communities.
B: Incorrect. Transfer to a skilled care facility is not a goal of PACE, which aims to prevent or delay institutionalization by providing coordinated care and support to older adults with chronic conditions and functional limitations.
C: Incorrect. Telehealth for pacemaker diagnostics is not a specific service offered by PACE, which provides primary care, specialty care, prescription drugs, home health care, personal care, transportation, and other services as needed.
D: Correct. Adult day care services are part of the PACE program, which helps older adults maintain their independence and quality of life by providing socialization, supervision, and assistance with activities of daily living.
Correct Answer is D
Explanation
Choice A reason
Ensuring that the client's family supports the provider's decision for surgery is not an appropriate action. While family support is essential in the decision-making process, the primary responsibility lies with the client's health care surrogate or designated decision-maker. The family's support is not a substitute for obtaining informed consent from the designated decision-maker.
Choice B reason
Sending the unsigned informed consent form to the facility's risk manager is not appropriate action. The nurse should not send an unsigned informed consent form to the facility's risk manager. Unsigned consent forms do not have any legal significance or validity. The nurse should work with the health care surrogate to ensure that the consent form is appropriately completed and signed.
Choice C reason
Determining if the procedure is medically necessary for the client is not appropriate action. While the medical necessity of the procedure is important, the decision about the procedure's necessity should be made by the medical team and discussed with the health care surrogate. The nurse's role is to facilitate communication and ensure that the surrogate is informed and involved in the decision-making process.
Choice D reason
When a client is in a coma and unable to provide informed consent, the health care surrogate or designated decision-maker becomes responsible for making medical decisions on behalf of the client. It is essential for the nurse to ensure that the health care surrogate is aware of the situation, understands the risks and benefits of the surgical procedure, and has provided informed consent on behalf of the client.
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