A nurse is collecting data from a child who has pertussis.
Which of the following manifestations should the nurse expect?

Facial erythema.

Beefy, red tongue.

Fever.

Koplik spots.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Facial erythema (redness of the face) is not a typical manifestation of pertussis (whooping cough) Pertussis primarily presents with a severe cough, often followed by a "whooping" sound during inhalation, and can cause complications like pneumonia and apnea. Facial erythema is not a characteristic sign of the disease.

Choice B rationale:

A beefy, red tongue is not a common manifestation of pertussis. This description is more suggestive of other conditions, such as vitamin deficiencies or certain infections. Pertussis primarily involves respiratory symptoms, and a red tongue is not a typical finding associated with the disease.

Choice C rationale:

Fever is a common manifestation of pertussis, and it is often one of the early symptoms. However, it is not the most specific sign of the disease, as many other infections can also cause fever. While fever can occur in pertussis, it is not the most distinctive feature of the condition.

Choice D rationale:

Koplik spots are not associated with pertussis but rather with measles (rubeola) Koplik spots are small white or grayish-blue spots with a red halo that appear on the mucous membranes inside the cheeks and are characteristic of measles. Pertussis is primarily known for its characteristic cough and paroxysms of coughing, not for Koplik spots.

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Correct Answer is C

Explanation

Choice A rationale:

Relocating the sensor every 8 hours is not necessary when obtaining oxygen saturation readings unless there is a specific clinical reason to do so, such as skin irritation or poor perfusion at the sensor site. Frequent relocation can cause unnecessary disruption for the patient.

Choice B rationale:

Waiting 10 seconds after placing the probe before obtaining the oxygen saturation reading is not required. Modern pulse oximeters provide real-time readings, and there is no need to wait after placing the probe. The reading is usually stable within seconds.

Choice C rationale:

Choosing a finger with a capillary refill time of less than 2 seconds is an essential consideration when obtaining oxygen saturation readings. Capillary refill time is a measure of peripheral perfusion, and choosing a finger with good perfusion ensures accurate oxygen saturation measurements.

Choice D rationale:

Placing the sensor probe on the same extremity as an electronic blood pressure cuff is generally acceptable. However, it is crucial to ensure that the sensor does not interfere with the blood pressure cuff's function and that it is securely attached to the patient's finger for accurate readings.

A. Gently massage the eyelid to facilitate absorption of the medication. B. Instruct guardian to apply erythromycin ophthalmic ointment every morning for 14 days. C. Place an occlusive dressing on the affected eye to prevent the spread of infection. D. Wipe any excess medication from the inner canthus outward.

Correct Answer is D

Explanation

The correct answer is d. Wipe any excess medication from the inner canthus outward.

Choice A reason: Gently massaging the eyelid is not recommended because it does not facilitate the absorption of ophthalmic ointment and may cause additional irritation or spread the infection.

Choice B reason: The instruction is incorrect because the child has been prescribed bacitracin, not erythromycin. It’s important to follow the prescribed medication and dosage instructions.

Choice C reason: Placing an occlusive dressing over the eye is not advised for bacterial conjunctivitis as it can create a moist environment that may promote bacterial growth.

Choice D reason: This is the correct action. After applying the ointment, wiping away excess from the inner canthus outward prevents the spread of infection and keeps the area clean. This method prevents potential irritation and ensures that the medication does not obstruct vision.

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A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining an oxygen saturation on a client.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a 3-year-old child who has acute bacterial conjunctivitis of the right eye and has been prescribed bacitracin ophthalmic ointment. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse is collecting data from a child who has pertussis.
Which of the following manifestations should the nurse expect?