A nurse is assisting with planning care for a school-age child who has suspected pertussis. Which of the following interventions is the nurse's priority to include?
Implementing droplet precautions
obtaining a nasopharyngeal culture
Encouraging family members' compliance with antibiotic therapy
Offering small amounts of oral fluids frequently
The Correct Answer is A
A. Implementing droplet precautions: Pertussis (whooping cough) is highly contagious and spreads through respiratory droplets. Implementing droplet precautions is essential to prevent the transmission of the infection to others, especially in a school-age child.
B. Obtaining a nasopharyngeal culture: While obtaining a culture is important for confirming the diagnosis of pertussis, the priority is to prevent the spread of the disease to others. Droplet precautions should be implemented immediately to reduce transmission.
C. Encouraging family members' compliance with antibiotic therapy: Antibiotic therapy is important for treating pertussis, but this is secondary to preventing the spread of infection. Once precautions are in place, encouraging adherence to the prescribed antibiotic regimen is necessary for the child's recovery.
D. Offering small amounts of oral fluids frequently: Maintaining hydration is important for a child with pertussis, especially as coughing can cause discomfort. However, the priority action is preventing the spread of the infection through droplet precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. “I will push the medication to the back of my baby's mouth quickly using a syringe":
Pushing medication to the back of the mouth quickly could cause the baby to gag or choke. It’s better to administer the medication slowly to ensure the baby swallows it safely.
B. "I will gently squeeze my baby's cheeks when giving the medication.": Gently squeezing the baby's cheeks helps guide the baby to open their mouth and accept the medication. This ensures safe administration of oral medications without causing discomfort or distress.
C. "I will add the medication to 8 ounces of formula": Adding medication to formula is not recommended as it can alter the medication's effectiveness and make it harder to ensure the correct dosage. It is better to give the medication separately from formula.
D. "I will mix the medication in a 4-ounce bowl of rice cereal at breakfast": Mixing the medication with rice cereal could lead to the baby not receiving the full dose if they do not finish the cereal. Medications should generally be administered separately to ensure the full dose is given.
Correct Answer is B
Explanation
A. Monitor vital signs every 8 hr: Vital signs should be monitored more frequently in a child with diabetic ketoacidosis (DKA) than every 8 hours. Monitoring every 1-2 hours is typically recommended in order to detect any signs of deterioration or complications early.
B. Initiate continuous cardiac monitoring: Cardiac monitoring is important in the management of DKA because the condition can lead to electrolyte imbalances (especially hypokalemia), which can affect heart rhythm and potentially cause arrhythmias.
C. Administer subcutaneous insulin 30 min before meals: In SKA, insulin should not be administered subcutaneously until the child’s condition is stabilized, as intravenous (IV) insulin is typically used initially to correct acidosis and hyperglycemia in DKA.
D. Implement fluid restrictions: Fluid restrictions are not appropriate in DKA. Aggressive fluid resuscitation is necessary to correct dehydration and restore proper electrolyte balance. Fluid restrictions could worsen dehydration and acidosis.
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