A nurse is planning care for a child who has varicella. Which of the following interventions should the nurse plan to include?

Administer aspirin for fever.

Initiate airborne precautions,

Assess the oral cavity for Koplik spots.

Provide the child with a warm blanket

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Administer aspirin for fever is incorrect. Aspirin is contraindicated in children with varicella due to the risk of Reye's syndrome. Reye's syndrome is a rare but serious condition that can occur when aspirin is given to children with certain viral infections, including varicella.

Choice B Reason:

Initiate airborne precautions is correct. Varicella is transmitted via airborne droplets. Use airborne precautions (negative air-flow rooms) for patients with varicella. If negative air-flow rooms are not available, isolate patients in closed rooms with no contact with people without evidence of immunity

Choice C Reason:

Assess the oral cavity for Koplik spots is incorrect. Koplik spots are associated with measles, not varicella. Varicella typically presents with a rash that starts on the trunk and spreads to the rest of the body, along with other symptoms like fever and malaise.

Choice D Reason:

Varicella can cause fever and discomfort, and providing a warm blanket can offer comfort to the child, helping to alleviate chills or discomfort associated with fever. However, it is more important to initiate airborne precautions.

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Correct Answer is D

Explanation

Choice A Reason:

Stretch the perineum taut when applying the bag. Taut stretching might cause discomfort or be unnecessary for applying the collection bag and could potentially disrupt the process.

Choice B Reason:

Apply lidocaine gel to the perineum before attaching the bag. Applying lidocaine gel isn't typically necessary for routine urine collection and might not be appropriate for this procedure in an infant without specific indications for its use.

Choice C Reason:

Place a snug-fitting diaper over the drainage bag. Placing a diaper over the collection bag might interfere with the collection process, cause the bag to shift, or create unnecessary pressure on the area.

Choice D Reason:

Position the opening of the bag over the urethra and the anus. Placing the opening of the collection bag over both the urethra and the anus increases the chances of capturing urine effectively. It allows for the collection of a clean catch urine sample while minimizing the risk of contamination from the anus.

A. Keep the infant in a visually stimulating environment. B. Assign consistent nursing staff to care for the infant. C. Give the infant fruit juice between feedings. D. Use half-strength formula when feeding the infant

Correct Answer is B

Explanation

Choice A Reason:

Keeping the infant in a visually stimulating environment might not directly address the nutritional or developmental needs of an infant with failure to thrive. While visual stimulation is essential for infant development, it's not the primary intervention for this condition.

Choice B Reason:

Assigning consistent nursing staff to care for the infant can provide stability and continuity, which can positively impact the infant's emotional well-being. However, this alone might not address the underlying issues related to failure to thrive.

Choice C Reason:

Giving the infant fruit juice between feedings might not be the best approach. Fruit juice can fill an infant's stomach without providing the necessary nutrients, potentially further reducing the intake of essential formula or breast milk.

Choice D Reason:

Using half-strength formula when feeding the infant isn't recommended without specific guidance from a healthcare provider. Diluting formula can compromise the infant's nutritional intake, potentially exacerbating the issue of failure to thrive.

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A nurse is planning care for a child who has varicella. Which of the following interventions should the nurse plan to include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to collect a urine specimen from a female infant using a urine collection bag. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A charge nurse is planning care for an infant who has failure to thrive. Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

Explanation

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