A nurse is caring for a toddler who has impetigo. Which of the following actions should the nurse take?

Inform the caregiver that it is okay to use the same towels.

Request the provider to prescribe an antiviral medication.

Place the toddler on droplet precautions.

Prevent the toddler from scratching their skin by using elbow restraints.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Inform the caregiver that it is okay to use the same towels: Sharing towels can spread impetigo, which is a highly contagious bacterial skin infection. Families should be instructed to use separate towels, washcloths, and linens to reduce the risk of cross-contamination.

B. Request the provider to prescribe an antiviral medication: Impetigo is caused by bacteria such as Staphylococcus aureus or Streptococcus pyogenes, not viruses. Antibacterial agents, not antivirals, are the appropriate treatment for managing this condition.

C. Place the toddler on droplet precautions: Impetigo primarily spreads through direct contact with lesions or contaminated objects, not respiratory droplets. Standard precautions with contact isolation are typically used rather than droplet precautions.

D. Prevent the toddler from scratching their skin by using elbow restraints: Scratching can worsen impetigo lesions and lead to further bacterial spread or secondary infection. Using soft restraints like elbow splints can safely discourage scratching and promote healing while preventing the infection from spreading.

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Correct Answer is A

Explanation

Rationale:

A. Instruct the client to lie supine with his knees flexed: Flexing the knees reduces tension on the abdominal wall and helps prevent further protrusion of abdominal contents. This position is critical for stabilizing the evisceration while awaiting surgical intervention.

B. Cover the wound with a dry sterile dressing: Using a dry dressing can cause the exposed organs to dry out and adhere to the material, increasing the risk of tissue damage. A moist sterile dressing is needed to protect and preserve the protruding tissues.

C. Position the client in semi-Fowler's position: Elevating the head of the bed increases intra-abdominal pressure and can worsen evisceration. This position should be avoided to prevent strain on the open surgical site.

D. Cover the wound with a transparent dressing: Transparent dressings are not suitable for eviscerations because they do not provide adequate moisture or protection for exposed organs. A sterile saline-moistened dressing is required to maintain tissue integrity.

A. Milk B. Whole wheat bread C. Red meat D. Almonds

Correct Answer is C

Explanation

Rationale:

A. Milk: Milk does not interfere with fecal occult blood testing and does not contain substances that cause false-positive results. It can be safely consumed prior to the test without affecting the accuracy of the results.

B. Whole wheat bread: Whole wheat bread is high in fiber, which is actually beneficial when preparing for a fecal occult blood test. It helps promote regular bowel movements but does not lead to false-positive results.

C. Red meat: Red meat contains heme, a form of animal blood, which can cause false-positive results on guaiac-based fecal occult blood tests. Avoiding red meat for at least 3 days prior to the test helps reduce the risk of inaccurate results.

D. Almonds: Almonds and other nuts do not contain components that interfere with fecal occult blood testing. They are not known to cause false-positive or false-negative results and are safe to consume before the test.

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A nurse is caring for a toddler who has impetigo. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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