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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Heart rate 110/min: A heart rate of 110 beats per minute is within the normal range for a 4-year-old child. The typical heart rate for this age is between 80 to 120 beats per minute.
B. Capillary refill greater than 3 seconds: Capillary refill time should be less than 2 seconds in a healthy child. A refill time greater than 3 seconds may indicate poor perfusion or dehydration, which is abnormal.
C. Weight gain of 0.9 kg (2 lb) in a year: A weight gain of 2 pounds in a year is below the expected range for a 4-year-old. Children in this age group typically gain around 4-5 pounds per year as they grow.
D. Respiratory rate 32/min: The normal respiratory rate for a 4-year-old child is typically between 20 to 30 breaths per minute. A rate of 32/min is slightly elevated and may indicate respiratory distress or other issues.
Correct Answer is D
Explanation
A. A school-age child who cries when the nurse is giving him an injection: Crying during an injection is a normal reaction for a child and does not indicate abuse.
B. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy: Bruises on the shins are common in toddlers due to normal play and falls. Without other concerning signs, this does not strongly indicate abuse.
C. A preschooler who has a BMI indicating obesity: While childhood obesity can be a sign of neglect in some cases, it is not a specific or immediate indicator of abuse without other signs.
D. An adolescent who asks to stay in the hospital because he likes the room: This is concerning because it might indicate that the adolescent is not feeling safe or comfortable at home, which could be a sign of abuse or neglect.
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