A nurse in the emergency department is caring for a child who has a temperature of 39.1° C (102.4° F) and a suspected diagnosis of bacterial meningitis. Which of the following actions should the nurse take first?

Administer an antipyretic to the child.

Dim the lights in the child's room.

Implement droplet precautions for the child.

Prepare the child for a lumbar puncture.

Answer and Explanation

The Correct Answer is C

A. "Administer an antipyretic to the child." While managing fever with antipyretics is important, it is not the immediate priority. Ensuring the child's safety and preventing the spread of infection are more urgent.

B. "Dim the lights in the child's room." While dimming the lights can help reduce discomfort and sensitivity in a child with meningitis, it is not the first priority. Implementing precautions and addressing infection control is more critical initially.

C. "Implement droplet precautions for the child." Bacterial meningitis is a communicable disease that can be spread via respiratory droplets. Implementing droplet precautions is crucial to prevent the spread of the infection to others and protect healthcare workers. This action should be taken first to ensure proper infection control.

D. "Prepare the child for a lumbar puncture." A lumbar puncture is an important diagnostic procedure for confirming bacterial meningitis, but it should only be performed after appropriate precautions are in place. Ensuring infection control measures are followed first is essential before proceeding with any diagnostic or treatment procedures.

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Correct Answer is ["D","E"]

Explanation

Choice A Reason:

Heat the formula to 39°C (102°F) prior to administration. Formula temperature should be warm, but heating it to a specific temperature like 39°C (102°F) is not typically necessary. Room temperature or slightly warm formula is often suitable.

Choice B Reason:

The supine position (lying flat on the back) is not recommended during enteral feedings. Infant should be placedin a semi-upright position (usually around 30 to 45 degrees)- this helps prevent aspiration and aids in proper digestion and passage of the feeding into the stomach.

Choice C Reason:

Offer the infant a pacifier during feedings. Offering a pacifier during enteral feedings could potentially interfere with the feeding process and may increase the risk of aspiration. It's generally not recommended during tube feedings.

Choice D Reason:

Instill the formula over a period of 30 to 45 minutes. Slowly administering the formula over this duration allows for proper digestion and reduces the risk of feeding-related complications.

Choice E Reason:

Check for residual volumes by aspirating stomach contents. Checking for residual volumes helps ensure the stomach is adequately emptying and can help prevent complications such as aspiration or feeding intolerance.

A. Instruct the child to drink fluids through a straw. B. Offer the child ice cream when alert. C. Place the child in a side-lying position. D. Encourage the child to deep breath and cough.

Correct Answer is C

Explanation

Correct answer: C

Choice A Reason:

Instructing the child to drink fluids through a straw should be avoided immediately after a tonsillectomy. The sucking motion required when using a straw can potentially disrupt the healing process and dislodge the blood clot at the surgical site, leading to bleeding. Therefore, this action is not recommended.

Choice B Reason:

Avoid milk products such as milk, icecream and pudding initially because they coat the throat, causing the child to cough to clear the throat.

Choice C Reason:

Placing the child in a side-lying position helps maintain an open airway and allows drainage of saliva and potential blood.

Choice D Reason:

Encouraging the child to deep breath and cough is generally a good practice to prevent respiratory complications post-anesthesia. However, immediate post-tonsillectomy, the focus might be more on airway patency and monitoring for signs of bleeding or adverse reactions rather than deep breathing and coughing.

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A nurse in the emergency department is caring for a child who has a temperature of 39.1° C (102.4° F) and a suspected diagnosis of bacterial meningitis. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

aA nurse is caring for an infant who receives intermittent enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take when administering a feeding? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

A nurse in a PACU is caring for a school-age child immediately following a tonsillectomy. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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