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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
The nurse should not remind the client to void every 4 hours because epidural anesthesia can cause temporary loss of bladder sensation, making it difficult for the client to know when to void. Instead, the nurse should use a bladder scanner to assess for urinary retention and encourage the client to void regularly.
Choice B reason:
Encouraging the client to alternate from side to side every 2 hours is not directly related to the administration of epidural anesthesia. This action is commonly advised for clients who are on bed rest to prevent pressure ulcers and promote circulation. However, it is not specifically necessary for the client receiving epidural anesthesia for pain management during labor.
Choice C reason:
Raising the four side rails on the client's bed is not necessary in this situation. The use of side rails should be based on the client's mobility and risk assessment for falls. If the client is receiving epidural anesthesia, they may experience reduced mobility, but the decision to use side rails should be made on an individual basis, not solely based on the anesthesia.
Choice D reason:
Monitoring the client's blood pressure is a crucial action when a client is receiving epidural anesthesia. Epidural anesthesia can cause a drop in blood pressure, leading to hypotension. By regularly monitoring the client's blood pressure, the nurse can detect any significant changes and take appropriate actions to maintain hemodynamic stability.
Correct Answer is C
Explanation
Choice A reason:
Hep B is given at birth, 2 months, and 6 months of age not at 11 years old.
Choice B reason:
Measles, mumps, rubella (MMR) The rationale for not choosing Measles, mumps, rubella (MMR) is the same as for choice A. If the child has already received the required doses of the MMR vaccine, giving extra doses is not necessary and may not provide any additional benefit.
Choice C reason:
This vaccine is recommended for children at age 11-12 years to boost immunity against tetanus, diphtheria, and pertussis. This is a one-time dose, and it's important to ensure that children receive it on schedule.
Choice D reason:
Pneumococcal (PCV) The rationale for not choosing Pneumococcal (PCV) is that this vaccine is typically given in infancy and early childhood as part of the routine immunization schedule.
Since the child is 11 years old and up to date with current recommendations, they are unlikely to require another dose of PCV at this stage.
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