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
The correct answer is: A. Tugging on the affected ear lobe.
Choice A reason:
Tugging on the affected ear lobe is a common sign of discomfort in children with otitis media. This behavior indicates that the child is experiencing pain or pressure in the ear, which is a typical symptom of this condition. Children often cannot verbalize their discomfort, so they may tug or pull at their ears to express their pain.
Choice B reason:
Erythema and edema of the affected ear are more indicative of otitis externa (swimmer's ear) rather than otitis media. Otitis media involves inflammation and infection of the middle ear, which is not typically visible externally. The primary signs of otitis media are observed through otoscopic examination, showing a bulging or erythematous tympanic membrane.
Choice C reason:
Pain when manipulating the affected ear lobe is also more characteristic of otitis externa. In otitis media, the pain is usually deeper within the ear and not exacerbated by touching the outer ear. The pain in otitis media is due to the pressure and inflammation in the middle ear space.
Choice D reason:
Clear drainage from the affected ear is not typical of otitis media. If there is drainage, it is usually purulent (pus-like) and indicates a ruptured eardrum due to the infection. Clear drainage is more commonly associated with conditions like otitis externa or a perforated eardrum without infection.
Correct Answer is A
Explanation
Choice A: Encouraging the parents to rock the infant is an appropriate action for a nurse to take, as it can provide comfort, security, and bonding for the infant who is recovering from surgery. Rocking can also soothe the infant's pain and distress and promote sleep and relaxation.
Choice B: Administering blood thinners as needed for pain is not an appropriate action for a nurse to take, as blood thinners are not analgesics and can cause bleeding complications in an infant who is postoperative. Blood thinners are medications that prevent or reduce blood clotting, which can increase the risk of hemorrhage or hematoma. The nurse should administer analgesics, such as acetaminophen or ibuprofen, as prescribed by the provider for pain relief.
Choice C: Positioning the infant on her abdomen is not an appropriate action for a nurse to take, as it can cause pressure or trauma to the surgical site and increase the risk of infection or dehiscence. Positioning the infant on her abdomen can also impair the infant's breathing and oxygenation and increase the risk of sudden infant death syndrome (SIDS). The nurse should position the infant on her back or side with her head elevated and supported.
Choice D: Offering the infant a pacifier is not an appropriate action for a nurse to take, as it can cause suction or friction on the surgical site and increase the risk of infection or dehiscence. Offering the infant a pacifier can also interfere with the infant's feeding and nutrition and cause nipple confusion or preference. The nurse should avoid giving the infant anything in her mouth except for a bottle or breast with a special nipple that does not touch the surgical site.
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