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.
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Related Questions
Correct Answer is C
Explanation
A. Gently cleanse the surgical site with sterile gauze: direct vigorous cleansing of the palate surgical site with gauze is generally avoided to prevent disruption of sutures. Oral rinses or specific gentle cleaning methods may be prescribed, but direct gauze wiping is usually not recommended.
B. Offer a pacifier with glucose syrup: acifiers and any sucking on objects (including straws, spoons, or toys) are typically contraindicated after cleft palate repair because the sucking motion puts stress on the suture line and can disrupt healing.
C. Apply elbow immobilizers to both arms: Elbow immobilizers prevent the infant from bending their elbows and bringing their hands to their mouth or face, which could disrupt the surgical sutures, cause trauma, or introduce infection to the delicate palate repair.
D. Place the infant in a supine position: A semi-upright position is usually preferred to reduce pressure on the surgical site and prevent aspiration, rather than placing the infant flat on their back.
Correct Answer is A
Explanation
A. Administer the vaccine in the vastus lateralis muscle using a 25-mm (1-in) needle: For infants, the vastus lateralis muscle in the thigh is the preferred site for intramuscular (IM) vaccinations, including the Hib vaccine. A 25-mm (1-in) needle is an appropriate length for this muscle in a 6-month-old infant.
B. Administer the vaccine subcutaneously in the abdomen using a 16-mm (5/8-in) needle: The Hib vaccine is not administered subcutaneously. It is an intramuscular injection, and the abdomen is not the recommended site for this vaccine.
C. Administer the vaccine subcutaneously in the upper arm using a 13-mm (1/2-in) needle: The Hib vaccine is administered intramuscularly, not subcutaneously. The upper arm is used for intramuscular injections in older children. A 13-mm needle is too short for an intramuscular injection in the vastus lateralis.
D. Administer the vaccine in the dorsogluteal muscle using a 51-mm (2-in) needle: The dorsogluteal muscle is not recommended for infants due to the risk of damaging the sciatic nerve. A 2-inch needle is too long for this area in an infant.
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