A nurse is assisting with the admission of a child who has measles. Which of the following isolation precautions should the nurse initiate?
Contact
Airborne
Protective environment
Droplet
The Correct Answer is B
Choice A: Contact isolation is not appropriate for a child who has measles, which is a highly contagious viral infection that causes fever, rash, cough, runny nose, and red eyes. Contact isolation is used for patients who have infections that can be spread by direct or indirect contact with the patient or their environment, such as wound infections, scabies, or Clostridioides difficile. Contact isolation requires wearing gloves and gowns and using dedicated equipment.
Choice B: Airborne isolation is appropriate for a child who has measles, as it is used for patients who have infections that can be spread by small droplets that can remain suspended in the air and travel over long distances, such as tuberculosis, chickenpox, or measles. Airborne isolation requires wearing a respirator mask and placing the patient in a negative pressure room with the door closed.
Choice C: Protective environment isolation is not appropriate for a child who has measles, as it is used for patients who have compromised immune systems and are at high risk of acquiring infections from others, such as transplant recipients, cancer patients, or patients receiving immunosuppressive therapy. Protective environment isolation requires wearing gloves, gowns, masks, and eye protection and placing the patient in a positive pressure room with high-efficiency particulate air (HEPA) filters.
Choice D: Droplet isolation is not appropriate for a child who has measles, as it is used for patients who have infections that can be spread by large droplets that can travel up to 6 feet from the source, such as influenza, pertussis, or meningitis. Droplet isolation requires wearing a surgical mask and eye protection and placing the patient in a private room or cohorting with other patients with the same infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: This statement is correct, as a fracture of an epiphyseal plate, which is a cartilage layer at the end of a long bone where growth occurs, can impair the normal growth and development of the bone. Depending on the type and severity of the fracture, the epiphyseal plate may close prematurely, stop growing, or grow unevenly, resulting in deformity, shortening, or angular deviation of the affected limb.
Choice B: This statement is incorrect, as a fracture of an epiphyseal plate does not necessarily disrupt the blood supply to the bone unless there is also damage to the periosteum, which is a membrane that covers and nourishes
the bone. A disruption of the blood supply to the bone can cause avascular necrosis, which is a condition that causes bone death due to lack of oxygen and nutrients.
Choice C: This statement is incorrect, as a fracture of an epiphyseal plate does not cause bone marrow loss through the fracture unless there is damage to the medullary cavity, which is a hollow space within the bone that contains bone marrow. Bone marrow loss through the fracture can cause bleeding, infection, or anemia.
Choice D: This statement is incorrect, as a fracture of an epiphyseal plate does not take longer to heal in younger children than in older children. In fact, younger children tend to heal faster than older children due to their higher metabolic rate, greater blood supply, and more active growth factors. The healing time of a fracture depends on various factors, such as the type and location of the fracture, the treatment method, and the presence of complications.
Correct Answer is C
Explanation
The correct answer is: c. Hold the infant’s chin to his chest and knees to his abdomen during the procedure.
Choice A: Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure.
Applying a eutectic mixture of lidocaine and prilocaine (EMLA) cream can help reduce pain during procedures like lumbar punctures. However, it typically needs to be applied 30 to 60 minutes before the procedure to be effective. Applying it only 15 minutes prior would not provide adequate analgesia.
Choice B: Keep the infant NPO for 6 hr prior to the procedure.
Keeping an infant NPO (nothing by mouth) for 6 hours is generally recommended before procedures requiring sedation or anesthesia to reduce the risk of aspiration. However, lumbar punctures do not typically require such prolonged fasting, especially in infants, unless sedation is planned.
Choice C: Hold the infant’s chin to his chest and knees to his abdomen during the procedure.
This is the correct positioning for a lumbar puncture in infants. The infant should be held in a curled-up position, with the chin to the chest and knees to the abdomen, to maximize the space between the vertebrae and allow easier access to the lumbar region. This position helps to stabilize the infant and reduce movement during the procedure.
Choice D: Place the infant in an infant seat for 2 hr following the procedure.
Post-procedure care for a lumbar puncture typically involves monitoring the infant for any signs of complications, such as headache or infection. Placing the infant in an infant seat for 2 hours is not a standard recommendation. Instead, the infant should be observed and allowed to rest comfortably.
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