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 B
Explanation
Choice A: This test will not indicate if the child has rheumatic fever, as rheumatic fever is a complication of an untreated or inadequately treated streptococcal infection that affects the heart, joints, skin, and brain. Rheumatic fever is diagnosed based on clinical criteria, such as carditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules.
Choice B: This test will confirm if the child had a recent streptococcal infection, as antistreptolysin O (ASO) is an antibody that the body produces in response to streptococcal bacteria. A high ASO titer indicates that the child was exposed to streptococcal bacteria within the past few weeks. A streptococcal infection can cause pharyngitis, tonsillitis, scarlet fever, or impetigo.
Choice C: This test will not indicate if the child has a therapeutic blood level of an aminoglycoside, as an aminoglycoside is a type of antibiotic that is used to treat serious bacterial infections. A therapeutic blood level of an aminoglycoside means that the drug is effective and safe in the body. A therapeutic blood level of an aminoglycoside is measured by a peak and trough level.
Choice D: This test will not confirm if the child has immunity to streptococcal bacteria, as immunity to streptococcal bacteria means that the body can resist or fight the infection. Immunity to streptococcal bacteria can be acquired by natural exposure or vaccination. Immunity to streptococcal bacteria is measured by an antibody titer or a skin test.
Correct Answer is B
Explanation
Choice A reason: This choice is incorrect because taking glyburide with breakfast is not recommended for an adolescent who has type 1 diabetes mellitus. Glyburide is an oral hypoglycemic medication that lowers blood glucose levels by stimulating insulin secretion from the pancreas. It may be used for clients who have type 2 diabetes mellitus, but it does not work for clients who have type 1 diabetes mellitus or DKA.
Choice B reason: This choice is correct because obtaining an influenza vaccine annually is recommended for an adolescent who has type 1 diabetes mellitus. The influenza vaccine is a vaccine that protects against influenza, a viral infection that affects the respiratory system. It may prevent or reduce the severity of influenza and its complications, such as pneumonia or sepsis. It is recommended for everyone who is 6 months or older, especially those who have chronic conditions such as diabetes mellitus that increase their risk of influenza-related complications.
Choice C reason: This choice is incorrect because administering glucagon for hyperglycemia is not indicated for an adolescent who has type 1 diabetes mellitus. Glucagon is a hormone that raises blood glucose levels by stimulating glycogen breakdown in the liver. It may be used for clients who have hypoglycemia, which is a condition in which blood glucose levels are lower than normal (less than 70 mg/dL). It may cause symptoms such as sweating, trembling, confusion, or loss of consciousness. However, in type 1 diabetes mellitus, hyperglycemia (high blood glucose levels) rather than hypoglycemia is more likely to occur due to insulin deficiency or resistance.
Choice D reason: This choice is incorrect because injecting insulin in the deltoid muscle is not an optimal method for an adolescent who has type 1 diabetes mellitus. Insulin is a hormone that lowers blood glucose levels by facilitating glucose uptake into the cells. It may be administered by injection or infusion, and it may vary in onset, peak, and duration of action. The preferred sites for insulin injection are the abdomen, the thighs, the buttocks, or the upper arms, as they have more subcutaneous fat and less muscle tissue. Injecting insulin into the deltoid muscle may cause faster absorption and shorter duration of action, which can affect blood glucose control and increase the risk of hypoglycemia.
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