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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Oliguria is incorrect. Low potassium levels (hypokalemia) may lead to decreased kidney function and reduced urine output (oliguria) in severe cases. However, at this potassium level, oliguria might not be the immediate or most prominent finding.
Choice B Reason:
Hyperactive bowel sounds are incorrect. Gastroenteritis typically presents with increased bowel sounds due to gastrointestinal irritation or inflammation. Potassium levels might not directly influence bowel sounds, so hyperactive bowel sounds might not be specifically related to the potassium level.
Choice C Reason:
Hyporeflexia is correct. Hypokalemia, indicated by a low potassium level, can affect nerve conduction and muscular function, potentially leading to hyporeflexia (reduced reflexes) as one of its manifestations. This can be a relevant finding associated with low potassium levels.
Choice D Reason:
Hypertension is incorrect. Hypokalemia is more commonly associated with hypotension (low blood pressure) rather than hypertension (high blood pressure). Therefore, hypertension is less likely to be an expected finding related to low potassium levels.
Correct Answer is A
Explanation
Choice A Reason:
Increased expectoration is correct. Increased expectoration (coughing up and clearing mucus) could indicate improved airway clearance, which is a primary goal of chest physiotherapy in cystic fibrosis. Effective therapy would facilitate the removal of mucus from the airways, making it easier for the child to clear secretions.
Choice B Reason:
Reduced pain is incorrect. While reducing pain is important for overall comfort, chest physiotherapy's primary goal in cystic fibrosis is to improve airway clearance and lung function. Pain reduction might not be the primary indicator of the therapy's effectiveness in this context.
Choice C Reason:
Increased heart rate is incorrect. An increased heart rate might not directly indicate the effectiveness of chest physiotherapy for cystic fibrosis. The focus is primarily on improving respiratory function and airway clearance rather than affecting heart rate.
Choice D Reason:
Increased urine output is incorrect. Increased urine output is not typically a direct indicator of the effectiveness of chest physiotherapy in cystic fibrosis. Chest physiotherapy aims to improve respiratory function rather than affecting urine output.
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