A nurse is caring for an infant who has pertussis. Which of the following precautions should the nurse implement?
Airborne.
Droplet.
Standard.
Neutropenic.
The Correct Answer is B
Choice A reason:
Airborne precautions are implemented for diseases that spread through small airborne particles, such as tuberculosis or measles. These diseases can remain suspended in the air for extended periods and be inhaled by others. Pertussis, also known as whooping cough, is primarily spread through respiratory droplets when an infected person coughs or sneezes, making airborne precautions unnecessary.
Choice B reason:
Droplet precautions are appropriate for illnesses that spread through respiratory droplets produced when an infected person talks, coughs, or sneezes. Pertussis falls into this category as it is transmitted mainly through respiratory droplets. By implementing droplet precautions, the nurse will minimize the risk of transmission to others, including healthcare workers and other patients.
Choice C reason:
Standard precautions are the baseline infection prevention practices used for all patients to prevent the spread of infections in healthcare settings. While important, they may not be sufficient to control the transmission of pertussis, as it requires additional measures like droplet precautions due to its specific mode of transmission.
Choice D reason:
Neutropenic precautions are used for patients with compromised immune systems, particularly those with low white blood cell counts (neutropenia). The purpose is to protect these vulnerable individuals from exposure to infectious agents. However, pertussis precautions are different and do not fall under the neutropenic category.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The nurse should include the statement that "This test measures amniotic fluid volume” in the teaching about the biophysical profile (BPP). The rationale for this is that the BPP is a prenatal screening tool that assesses the well-being of the fetus. One of the components of the BPP is the measurement of amniotic fluid volume, which helps to evaluate fetal kidney function and overall fetal health.
Choice B reason:
The nurse should not include the statement about receiving Rh(D) immune globulin prior to the test because it is not directly related to the biophysical profile (BPP). Rh(D) immune globulin is given to Rh-negative pregnant women to prevent hemolytic disease of the newborn (HDN) if the fetus is Rh-positive. While this may be important information during pregnancy, it is not specific to the BPP.
Choice C reason:
The nurse should not include the statement that "This test is used to assess uterine activity” in the teaching about the BPP. The BPP is a test focused on evaluating fetal well-being and not uterine activity. Uterine activity is typically assessed through other methods, such as monitoring contractions during labor.
Choice D reason:
The correct answer is not Choice D. The nurse should not include the statement that "Your bladder needs to be full to perform this test” in the teaching about the BPP. This statement is incorrect because a full bladder is not necessary for the BPP. Instead, the BPP involves the use of ultrasound to assess fetal movements, breathing, muscle tone, and amniotic fluid volume, and a full bladder is not a requirement for this assessment.
Correct Answer is C
Explanation
Choice A reason:
The nurse should not offer the child sips of clear liquids during a seizure. During a tonic-clonic seizure, the child's swallowing reflex may be impaired, and giving liquids could lead to aspiration or choking, causing further complications.
Choice B reason:
The nurse should not restrain the child during a seizure using both arms or any other means. Restraint can potentially lead to injury for both the child and the person attempting to restrain them. It is crucial to allow the child to move freely during the seizure to prevent harm.
Choice C reason:
Placing the child's head on a pillow is the correct choice. This positioning helps to protect the child's head from injury during the seizure. The pillow provides a cushioning effect, minimizing the risk of head trauma.
Choice D reason:
The nurse should not instruct the parent to give rectal diazepam to the child at the onset of the seizure unless specifically prescribed by the child's healthcare provider. Diazepam is a medication used to manage seizures, but its administration route and timing should be determined by the child's healthcare provider. Inappropriate use of medication can be dangerous and ineffective.
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