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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. "This will not be painful, just a little uncomfortable." While this statement might provide some reassurance, it does not actively engage the child or make the task of taking deep breaths more enjoyable.

B. "Let's play a game of blowing cotton balls across your table." This is the best choice as it makes deep breathing fun and engaging for the child, encouraging them to participate without feeling like it’s a chore.

C. "Do you want to take deep breaths for me now?" This approach is too passive and doesn't engage the child actively or make the activity interesting.

D. "You can't go to the playroom until you finish doing your deep breathing." This approach can create negative reinforcement and might make the child associate deep breathing with punishment or coercion, which is not desirable.

A. Determine if the toddler is voiding. B. Request evaluation of the toddler's serum electrolytes. C. Initiate isotonic fluids with 20 mEq/L potassium chloride. D. Collect a stool sample from the toddler.

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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A nurse is assisting with the admission of a child who has pertussis. Which of the following actions should the nurse take?

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