A nurse is admitting a child who has pertussis. Which of the following transmission-based precautions should the nurse initiate?
Contact
Airborne
Protective
Droplet
The Correct Answer is D
Choice A reason: Contact precautions are used for infections that spread by direct or indirect contact with the patient or the patient's environment. While important, they are not the primary precaution for pertussis.
Choice B reason: Airborne precautions are used for diseases that are transmitted through the air over long distances, such as tuberculosis. Pertussis does not typically require airborne precautions.
Choice C reason: Protective precautions are used to protect immunocompromised patients from being infected by others. This is not applicable for a child with pertussis, who is the source of infection.
Choice D reason: Droplet precautions are used for diseases that are transmitted through large droplets expelled during coughing, sneezing, or talking. Pertussis, also known as whooping cough, is primarily spread through respiratory droplets, making droplet precautions the appropriate choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A creatinine level of 1.4 mg/dL is higher than the normal range for a 4-year-old child and could indicate kidney impairment, which is a concern when administering gentamicin due to its potential nephrotoxic effects. The provider should be informed immediately to assess kidney function and adjust the medication if necessary.
Choice B reason: A BUN level of 6 mg/dL is within the normal range for children and does not typically warrant immediate concern. However, it should be monitored along with creatinine levels to assess kidney function.
Choice C reason: A creatinine level of 0.3 mg/dL is within the normal range for a 4-year-old child and does not indicate an immediate concern. It should be monitored for any changes, especially when on gentamicin.
Choice D reason: A BUN level of 12 mg/dL is slightly elevated but may not be immediately concerning. It should be evaluated in conjunction with other laboratory values and clinical findings.
Correct Answer is A
Explanation
Choice A reason: Irregular bluish pigmentation on the sacral area could indicate a Mongolian spot, which is common and usually harmless, but it could also suggest other conditions that may require further evaluation. Reporting this finding is important for proper assessment and documentation.
Choice B reason: Slow, rhythmic movements of the lower extremities are normal in newborns and are known as primitive reflexes. These movements are expected and do not typically require reporting unless they are absent or abnormal.
Choice C reason: An anterior fontanel size of 3 cm (1.2 in) is within the normal range for a newborn. The fontanel should be soft and flat, and changes in size or tension should be monitored over time.
Choice D reason: Enlarged breasts in newborns are also common due to maternal hormones and usually resolve without intervention. It is not a finding that typically requires immediate reporting unless there is redness, swelling, or discharge.
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