A nurse is assisting with the admission of a child who has pertussis. Which of the following actions should the nurse take?
Initiate droplet precautions.
Initiate a protective environment.
Initiate contact precautions.
Initiate airborne precautions.
The Correct Answer is A
A. Initiate droplet precautions. Pertussis (whooping cough) is transmitted via respiratory droplets. Droplet precautions are necessary to prevent the spread of the disease through coughs or sneezes.
B. Initiate a protective environment. A protective environment is used for patients with severe immunocompromised conditions to protect them from infections, not to prevent the spread of respiratory infections like pertussis.
C. Initiate contact precautions. Contact precautions are used for infections spread by direct or indirect contact with the patient or their environment, such as MRSA. Pertussis is spread by droplets, not by contact.
D. Initiate airborne precautions. Airborne precautions are for diseases that are spread through airborne particles, such as tuberculosis or measles. Pertussis is not airborne but spread through larger respiratory droplets.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will provide low-fat meals for my child.": Children with cystic fibrosis need a high-calorie, high-fat diet to meet their increased energy needs and to help with growth and development due to malabsorption issues.
B. "I will restrict the amount of salt in my child's meals.": Children with cystic fibrosis tend to lose more salt through sweat and often require additional salt in their diet.
C. "I will put my child in daycare to ensure that she socializes with other children.": While socialization is important, children with cystic fibrosis are at higher risk for respiratory infections and should avoid environments where they are more likely to be exposed to pathogens.
D. "I will make sure my child washes her hands before eating.": Hand hygiene is crucial for preventing infections, which are a significant risk for children with cystic fibrosis due to their compromised lung function.
Correct Answer is A
Explanation
A. Determine if the toddler is voiding: Assessing urine output is crucial for determining the child’s hydration status. Voiding is an important indicator of kidney function and fluid balance. Ensuring the child is voiding can help determine the severity of dehydration and guide further interventions.
B. Request evaluation of the toddler's serum electrolytes. Evaluating serum electrolytes is important for understanding the extent of dehydration and electrolyte imbalances. However, it is not the immediate first action and should follow the initial assessment of the child's hydration status.
C. Initiate isotonic fluids with 20 mEq/L potassium chloride. Initiating fluid therapy is crucial but should only be done after assessing kidney function through urine output and evaluating the need for potassium supplementation to avoid complications like hyperkalaemia if the kidneys are not functioning properly.
D. Collect a stool sample from the toddler. Collecting a stool sample is useful for diagnosing the cause of gastroenteritis, but it is not the immediate priority. The focus should first be on assessing hydration status and initiating appropriate fluid therapy.
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