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?
Prepare the child for a lumbar puncture.
Dim the lights in the child's room.
Administer an antipyretic to the child.
Implement droplet precautions for the child.
The Correct Answer is D
The correct answer is choice d. Implement droplet precautions for the child.
Choice A rationale:
Preparing the child for a lumbar puncture is important for diagnosing bacterial meningitis, but it is not the first action. Immediate infection control measures are more critical to prevent the spread of the disease.
Choice B rationale:
Dimming the lights can help reduce discomfort from photophobia, a common symptom of meningitis, but it is not the priority action when first addressing a suspected case of bacterial meningitis.
Choice C rationale:
Administering an antipyretic to reduce fever is important for comfort and to manage symptoms, but it does not address the immediate need to prevent the spread of infection.
Choice D rationale:
Implementing droplet precautions is the first action the nurse should take. Bacterial meningitis can be highly contagious, and droplet precautions help prevent the spread of the infection to other patients and healthcare workers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice b. Stretch the perineum taut when applying the bag.
Choice A rationale:
Positioning the opening of the bag over both the urethra and the anus is incorrect because it increases the risk of contamination from fecal matter, which can lead to inaccurate test results.
Choice B rationale:
Stretching the perineum taut when applying the bag ensures a secure fit and reduces the risk of leakage, which is essential for accurate urine collection.
Choice C rationale:
Applying lidocaine gel to the perineum before attaching the bag is not recommended as it is unnecessary and could cause irritation or an allergic reaction in the infant.
Choice D rationale:
Placing a snug-fitting diaper over the drainage bag is not the correct action because it can cause the bag to become dislodged or compressed, leading to inaccurate collection or spillage.
Correct Answer is C
Explanation
When caring for a school-age child immediately following a tonsillectomy in the Post-Anesthesia Care Unit (PACU), the nurse should prioritize actions that promote the child's comfort and recovery while minimizing the risk of complications. The most appropriate action is:
c) Offer the child ice cream when alert.
After a tonsillectomy, cold and soothing foods like ice cream can help alleviate throat pain and reduce swelling. However, it's crucial to wait until the child is fully alert and able to swallow safely. Ice cream provides a cool and gentle way to soothe the surgical site.
The other options may not be suitable immediately following a tonsillectomy:
a) Placing the child in a side-lying position: While positioning can be essential for airway management, it's not a specific intervention related to a tonsillectomy in the immediate postoperative period.
b) Instructing the child to drink fluids through a straw: Drinking through a straw may increase the risk of bleeding, which is a concern after a tonsillectomy. It's often recommended to avoid straws initially.
d) Encouraging the child to deep breathe and cough: While respiratory care is generally important, the immediate focus after a tonsillectomy is on maintaining a clear airway and managing pain. Deep breathing and coughing exercises may be introduced later in the recovery process.
It's important for the nurse to follow the specific postoperative guidelines provided by the surgical team and be attentive to the child's individual needs and responses.
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