A nurse is planning care for a child who has mumps. Which of the following instructions should the nurse include in the plan?
Initiate contact precautions.
Initiate standard precautions.
Initiate airborne precautions.
Initiate droplet precautions.
The Correct Answer is D
Choice A: Contact precautions are not necessary for a child who has mumps, as mumps is not transmitted by direct or indirect contact with the infected person or their environment. Contact precautions are used for infections that are spread by contact with skin, wounds, body fluids, or contaminated surfaces.
Choice B: Standard precautions are always used for any patient care, regardless of their diagnosis or infection status. Standard precautions include hand hygiene, use of personal protective equipment (PPE), safe injection practices, and proper disposal of waste and sharps. However, standard precautions alone are not sufficient for a child who has mumps, as mumps are transmitted by respiratory droplets.
Choice C: Airborne precautions are not necessary for a child who has mumps, as mumps are not transmitted by small particles that remain suspended in the air and can be inhaled by others. Airborne precautions are used for infections that are spread by airborne transmission, such as tuberculosis, measles, or chickenpox.
Choice D: Droplet precautions are required for a child who has mumps, as mumps are transmitted by large respiratory droplets that are expelled when the infected person coughs, sneezes, or talks. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, placing the patient in a private room or cohorts with other patients with the same infection, and limiting visitors and staff who are susceptible to the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: A 13% weight loss is a sign of severe dehydration in an infant, as it indicates a significant loss of body fluids and electrolytes. Dehydration can occur in an infant who has acute gastroenteritis, which is a condition that causes inflammation of the stomach and intestines, leading to vomiting and diarrhea. A 13% weight loss can also cause other signs of dehydration, such as sunken eyes, dry mouth, decreased urine output, and lethargy.
Choice B: A bulging anterior fontanel is not a sign of dehydration in an infant, but rather a sign of increased intracranial pressure, which can be caused by various conditions, such as meningitis, encephalitis, or head trauma. A bulging anterior fontanel can also cause other signs of increased intracranial pressure, such as irritability, headache, vomiting, or seizures.
Choice C: A capillary refill of 3 seconds is not a sign of dehydration in an infant, but rather a sign of normal perfusion and circulation. Capillary refill is the time it takes for the color to return to the nail bed after applying pressure. A normal capillary refill is less than 2 seconds. A prolonged capillary refill of more than 2 seconds can indicate poor perfusion and circulation, which can be caused by various conditions, such as shock, hypothermia, or heart failure.
Choice D: Bradypnea is not a sign of dehydration in an infant, but rather a sign of decreased respiratory rate, which can be caused by various conditions, such as hypoxia, narcotic overdose, or brain injury. Bradypnea can also cause other signs of respiratory distress, such as cyanosis, confusion, or loss of consciousness.
Correct Answer is D
Explanation
Choice A: This instruction is incorrect, as withholding insulin dose if feeling nauseous can cause hyperglycemia, which is high blood sugar, and diabetic ketoacidosis, which is a life-threatening condition that occurs when the body breaks down fat for energy and produces ketones. Ketones are acidic substances that can cause nausea, vomiting, abdominal pain, dehydration, or coma. The child should take their insulin dose as prescribed and monitor their blood sugar levels more frequently when they are sick.
Choice B: This instruction is unnecessary, as notifying the provider if blood glucose levels are within normal parameters does not require any action or intervention. The child and the parents should notify the provider if blood glucose levels are above or below the target range, which is usually 70 to 180 mg/dL for children with type 1 diabetes mellitus. The child and the parents should also notify the provider if they have any signs or symptoms of hypoglycemia, hyperglycemia, or diabetic ketoacidosis.
Choice C: This instruction is incorrect, as limiting fluid intake during mealtime can cause dehydration, which can worsen the symptoms and complications of type 1 diabetes mellitus. Dehydration can cause increased thirst, dry mouth, fatigue, headache, or dizziness. The child should drink plenty of fluids during meal time and throughout the day to hydrate their body and flush out excess glucose and ketones.
Choice D: This instruction is correct, as testing the urine for ketones can help detect diabetic ketoacidosis, which is a life-threatening condition that occurs when the body breaks down fat for energy and produces ketones. Ketones are acidic substances that can cause nausea, vomiting, abdominal pain, dehydration, or coma. The child should test their urine for ketones when their blood sugar levels are above 240 mg/dL or when they are sick. The child and the parents should notify the provider if the urine test shows moderate or large amounts of ketones.
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