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. Avoid a diet consisting of primarily milk. Milk, especially cow’s milk, is low in iron and can inhibit iron absorption. Excessive milk consumption can also lead to iron deficiency anemia by displacing iron-rich foods from the diet and potentially causing gastrointestinal bleeding in infants. Limiting milk intake and ensuring a balanced diet can help prevent iron deficiency.
B. Include whole grains and legumes in the diet. Whole grains and legumes are good sources of nonheme iron, which is beneficial for preventing iron deficiency anemia. While this is a good dietary recommendation, infants might not consume enough of these foods to meet their iron needs without additional sources or supplements.
C. Administer fat-soluble vitamins daily. Rationale: Fat-soluble vitamins (A, D, E, K) are not directly related to preventing iron deficiency anemia. They are important for other aspects of health, but they do not address iron intake or absorption.
D. Limit intake of high-protein foods. Rationale: High-protein foods like meat are often rich in heme iron, which is easily absorbed and important for preventing anaemia. Limiting these foods would not be beneficial and might even contribute to anemia.
Correct Answer is B
Explanation
A. Capillary refill less than 2 seconds: A capillary refill time of less than 2 seconds indicates good peripheral circulation, which is normal and not a cause for concern in this context. It is not the priority.
B. Tingling in the right foot Rationale: Tingling (paraesthesia) can be a sign of nerve damage or compromised circulation, which may indicate complications such as compartment syndrome. This is a priority finding because it can lead to severe consequences if not addressed promptly.
C. 2+ right pedal pulse Rationale: A 2+ pedal pulse indicates a normal pulse strength, which suggests that there is adequate blood flow to the extremity. It is not a priority compared to the potential for neurological or circulatory compromise.
D. Respiratory rate 24/min Rationale: A respiratory rate of 24/min is within the normal range for a school-age child (18-30 breaths per minute). While it is important to monitor vital signs, it is not a priority concern related to the fracture.
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