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 D
Explanation
A. Edema: Edema can occur with heart failure, but it is not specifically an indication of digoxin toxicity. Digoxin helps improve heart function and reduce edema, so it is not a direct sign of toxicity.
B. Jaundice: Jaundice may indicate liver dysfunction, but it is not a common sign of digoxin toxicity. Liver function issues can arise from various causes, but jaundice is not typically associated with digoxin toxicity.
C. Purulent sputum: Purulent sputum suggests an infection, such as pneumonia, and is not related to digoxin toxicity. This symptom requires further evaluation for respiratory infections, not digoxin-related issues.
D. Bradycardia: Bradycardia (a slow heart rate) is a classic sign of digoxin toxicity. Digoxin can slow the heart rate by affecting the electrical conduction system of the heart, and bradycardia is a key indicator of overdose or toxicity in infants and children taking this medication.
Correct Answer is ["A","C","E"]
Explanation
A. Ensure the scale is balanced to "0" before weighing the infant: It is important to calibrate the scale to "0" before weighing the infant to ensure an accurate measurement. This step helps to avoid any errors in weight assessment.
B. Place a stadiometer on the top of the infant's head to measure their length: A stadiometer is typically used for measuring height in older children and adults, but for infants, a length board (not a stadiometer) should be used.
C. Cover the scale with a clean sheet of paper: This is essential for hygiene and to provide a clean, warm surface for the infant, especially when they are undressed for weighing.
D. Obtain the infant's weight with their diaper on: To obtain an accurate weight, the infant should be weighed without the diaper. A diaper adds weight that could affect the accuracy of the measurement.
E. Measure the infant's length from the crown of the head to the heels of the feet: For accurate length measurements in infants, the measurement should be taken from the crown of the head to the heels of the feet while the infant is lying flat on a length board.
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