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 D
Explanation
Choice A: This prescription does not need clarification, as medicating the client for pain every 4 hours as needed is appropriate for a child who has suspected appendicitis. Appendicitis is a condition that causes inflammation and infection of the appendix, which is a small pouch attached to the large intestine. Appendicitis can cause severe abdominal pain, nausea, vomiting, fever, or loss of appetite. Pain medication can help relieve the discomfort and reduce inflammation.
Choice B: This prescription does not need clarification, as maintaining NPO status is appropriate for a child who has suspected appendicitis. NPO status means nothing by mouth, which means no food or fluids are given to the client. NPO status can prevent further irritation of the appendix and prepare the client for possible surgery.
Choice C: This prescription does not need clarification, as monitoring oral temperature every 4 hours is appropriate for a child who has suspected appendicitis. Oral temperature is a measure of body temperature taken by placing a thermometer under the tongue. Oral temperature can indicate infection or inflammation in the body. Monitoring oral temperature every 4 hours can help detect changes in the client's condition and guide treatment.
Choice D: This prescription needs clarification, as administering an enema is not appropriate for a child who has suspected appendicitis. An enema is a procedure that involves inserting a tube into the rectum and injecting fluid into the colon to stimulate bowel movement. An enema can cause perforation or rupture of the appendix, which can lead to peritonitis, which is inflammation of the peritoneum, which is the membrane that lines the abdominal cavity. An enema can also increase the risk of bleeding or infection.
Correct Answer is A
Explanation
Choice A: A WBC count of 17,000/mm³ is an abnormal result that the nurse should anticipate when reviewing this client's laboratory values, as it indicates leukocytosis, which is an increase in white blood cells. Leukocytosis can occur in a child who has cystic fibrosis (CF), which is a condition that causes thick mucus to block the airways and lungs and causes respiratory infections and inflammation. A normal WBC count for children is 5,000 to 10,000/mm³.
Choice B: A neutrophil count of 3,000/mm³ is not an abnormal result that the nurse should anticipate when reviewing this client's laboratory values, as it indicates normal neutrophil levels. Neutrophils are a type of white blood cell that fight bacterial infections. A normal neutrophil count for children is 1,500 to 8,000/mm³.
Choice C: A lymphocyte count of 3,000/mm³ is not an abnormal result that the nurse should anticipate when reviewing this client's laboratory values, as it indicates normal lymphocyte levels. Lymphocytes are a type of white blood cell that fight viral infections. A normal lymphocyte count for children is 1,500 to 4,000/mm³.
Choice D: An RBC count of 4.2 million/mm³ is not an abnormal result that the nurse should anticipate when reviewing this client's laboratory values, as it indicates normal red blood cell levels. Red blood cells carry oxygen and carbon dioxide throughout the body. A normal RBC count for children is 4 to 5.5 million/mm³.
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