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A nurse in an emergency department is caring for a school-age child.

Exhibits

The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.

Maintain NPO status.

Administer an antipyretic.

Initiate an infusion of IV fluids.

Administer a cleansing enema.

Prepare child and parents for ostomy placement.

Educate child and parents about plan of care.

Administer an analgesic.

Administer antibiotics.

Answer and Explanation

Correct Answer : A,B,C,F,G,H

A. Maintain NPO status. The child is at risk for surgery, and maintaining NPO status reduces the risk of aspiration.
B. Administer an antipyretic. Reducing fever can improve comfort and decrease metabolic demand.
C. Initiate an infusion of IV fluids. IV fluids prevent dehydration, especially since the child has had poor oral intake and diarrhea.
D. Administer a cleansing enema. An enema is contraindicated as it may worsen abdominal inflammation or cause perforation.
E. Prepare child and parents for ostomy placement. While surgery may be needed, an ostomy is not always required for appendicitis.
F. Educate child and parents about plan of care. Providing education helps reduce anxiety and ensures understanding of the interventions.
G. Administer an analgesic. Pain management is essential for comfort and reduces physiologic stress.
H. Administer antibiotics. Antibiotics are started preoperatively to manage infection or prevent complications if perforation is suspected.

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Correct Answer is A

Explanation

A. Nutritionist. The toddler’s BMI (28) indicates obesity, necessitating a referral for nutritional counseling to guide healthier dietary practices.
B. Speech therapist. The toddler demonstrates age-appropriate speech development, including forming short sentences such as "want go home now."
C. Physical therapist. The toddler meets gross motor developmental milestones such as running, kicking, and throwing a ball.
D. Occupational therapist. The toddler’s ability to feed themselves using finger foods and utensils indicates appropriate fine motor skills.

A. Initiate contact precautions. B. Perform chest percussion and postural drainage. C. Encourage clear liquids by mouth. D. Administer IV antibiotics.

Correct Answer is A

Explanation

A. Initiate contact precautions: RSV is a highly contagious respiratory virus spread via droplets and direct contact. To prevent transmission to others, contact precautions should be initiated.
B. Perform chest percussion and postural drainage: While these techniques can be used in some respiratory conditions, they are not the first-line intervention for RSV.
C. Encourage clear liquids by mouth: While oral rehydration may be appropriate in some cases of mild dehydration, this infant is likely experiencing respiratory distress, and oral intake may be difficult. Intravenous fluids may be required, especially if the infant is having difficulty feeding.
D. Administer IV antibiotics: RSV is caused by a virus, not a bacterial infection, so antibiotics are not effective in treating the infection.

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A nurse in an emergency department is caring for a school-age child. Exhibits The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.

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Exhibits

The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.