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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.

B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.

C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.

D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.

A. "Repeat the dose if your child vomits within 1 hour after taking the medication." B. "You can add the medication to a half-cup of your child's favorited juice." C. "Have your child drink a small glass of water after swallowing the medication." D. "Limit your child's potassium intake while she is taking this medication."

Correct Answer is C

Explanation

Choice A reason:

"Repeat the dose if your child vomits within 1 hour after taking the medication." This statement is incorrect. If a child vomits within 1 hour after taking digoxin, the parents should not repeat the dose. The reason is that the child may have already absorbed a sufficient amount of the medication before vomiting, and an additional dose could lead to digoxin toxicity.

Choice B reason:

"You can add the medication to a half-cup of your child's favourite juice." This statement is incorrect. Adding digoxin to juice or any other food or drink is not recommended. Digoxin should be administered separately and not mixed with food or liquids to ensure accurate dosing and prevent potential interactions with other substances.

Choice C reason:

"Have your child drink a small glass of water after swallowing the medication." This statement is correct. Giving a small glass of water after administering digoxin helps ensure that the medication is fully swallowed and goes into the stomach, reducing the risk of it being retained in the mouth or throat.

Choice D reason:

"Limit your child's potassium intake while she is taking this medication." This statement is not accurate. Digoxin is often prescribed in conjunction with other heart failure medications, some of which may impact potassium levels. However, the parents should not arbitrarily limit the child's potassium intake without specific instructions from the healthcare provider. The healthcare provider will monitor the child's potassium levels and adjust the treatment plan as necessary.

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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?

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