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 C
Explanation
A. Taking the infant's vital signs every 2 hr: Monitoring vital signs every 2 hours can help assess the infant’s general condition and detect changes in heart rate and blood pressure, which can indicate changes in hydration status. However, it might not be sufficient alone to monitor fluid status.
B. Counting the number of wet diapers every shift: Tracking the number of wet diapers is an effective way to monitor the infant's fluid output and hydration status. An increase in wet diapers typically indicates improved hydration. This is a practical and non-invasive method for assessing the effectiveness of IV therapy in infants.
C. Weighing the infant at the same time every day: Daily weights are a critical measure of fluid balance in infants. A consistent daily weight check provides a direct and accurate assessment of the infant’s hydration status and response to IV therapy.
D. Measuring the infant's head circumference twice per day: Measuring head circumference is not relevant for monitoring hydration status. It is typically used to assess growth and development in infants, not fluid balance or response to IV therapy.
Correct Answer is A
Explanation
A. "My baby's fingers are looking swollen.": Swelling around the IV site can indicate infiltration, where IV fluids leak into surrounding tissues rather than being infused into the vein.
B. "The tape is coming off the IV needle.": While loose tape may need to be replaced, it does not specifically indicate infiltration.
C. "There's blood backing up my baby's IV tubing.": Blood backflow can indicate various issues such as improper placement or the IV being too low, but not necessarily infiltration.
D. "There's a long red streak up my baby's arm.": A red streak can indicate phlebitis, inflammation of the vein, rather than infiltration, which typically presents with swelling and coolness around the IV site.
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