A nurse is planning care for a child who has varicella.
Which of the following interventions should the nurse plan to include?
Initiate airborne precautions.
Provide the child with a warm blanket.
Assess the oral cavity for Koplik spots.
Administer aspirin for fever.
The Correct Answer is A
Choice A rationale:
Varicella (chickenpox) is highly contagious and spreads through the air via respiratory droplets. Initiating airborne precautions, such as wearing masks and isolating the patient in a negative pressure room, helps prevent the spread of the virus to other patients and healthcare workers.
Choice B rationale:
Providing a warm blanket is a comfort measure and does not address the contagious nature of varicella. While keeping the child comfortable is important, preventing the spread of the infection to others is a higher priority.
Choice C rationale:
Koplik spots are small, white spots with blue or red centers that can appear on the oral mucosa in individuals with measles. Varicella does not cause Koplik spots; this finding is specific to measles. Therefore, assessing for Koplik spots is not relevant in the context of varicella.
Choice D rationale:
Administering aspirin to a child with varicella is contraindicated due to the risk of Reye's syndrome, a potentially fatal condition characterized by acute brain and liver damage. Acetaminophen is the preferred antipyretic for managing fever in children with varicella.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Teaching the child about cast care is essential, but it is not the first priority. The immediate concern is addressing the child's comfort and preventing complications associated with the fractured right tibia. Teaching can come after addressing the acute needs.
Choice B rationale:
Petaling the edges of the cast might be necessary to prevent skin irritation, but it is not the first action to take. Elevating the child's leg is crucial to reduce swelling and promote blood circulation, which is the priority in this situation.
Choice C rationale:
Administering pain medication is important for the child's comfort, but it should not be the first action. Elevating the leg helps in reducing pain and swelling and promotes overall healing.
Choice D rationale:
Elevating the child's leg is the first action the nurse should take. Elevating the leg above heart level helps reduce swelling and improves blood circulation, which is crucial in the initial phase after applying the cast. This action can help prevent complications and promote the healing process. Once the leg is elevated, the nurse can then proceed with teaching the child about cast care and administering pain medication if needed.
Correct Answer is D
Explanation
Choice A rationale:
Weighing the child once each month is not the most relevant information to include in teaching parents of a preschool-age child with heart failure. Monitoring weight is important, but it should be done more frequently, preferably daily, to track any sudden weight gain, which could indicate fluid retention and worsening heart failure.
Choice B rationale:
Withholding digoxin if the child's pulse is greater than 100/min is not appropriate. Digoxin is commonly prescribed for heart failure in pediatric patients to strengthen the heartbeat. Instead, the nurse should teach the parents to monitor the child's pulse rate regularly and report any significant changes to the healthcare provider.
Choice C rationale:
Increasing the child's oxygen flow rate until the child no longer has cyanosis is incorrect. While oxygen therapy might be necessary for a child with heart failure, adjusting the oxygen flow rate based on cyanosis is not the appropriate approach. Oxygen therapy should be prescribed and monitored by healthcare providers based on the child's oxygen saturation levels.
Choice D rationale:
Providing for periods of rest is the correct choice. Children with heart failure often tire easily due to the heart's reduced ability to pump blood effectively. Allowing the child to rest helps conserve energy and prevents additional strain on the heart. This instruction promotes the overall well-being and comfort of the child, aligning with the management of heart failure.
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