A nurse is planning care for a toddler who has measles. Which of the following isolation precautions should the nurse initiate?

Rationale

A. Assist the client in discussing their feelings about having diabetes mellitus: This action targets the affective domain of learning, which focuses on emotions, attitudes, and values. It helps the client process feelings about their diagnosis but does not develop hands-on skills or motor abilities.

B. Ask the client to attend a class about following a diabetic diet: Attending a class primarily addresses the cognitive domain by providing knowledge about nutrition and meal planning. It supports understanding but does not involve practicing physical skills or motor tasks.

C. Show the client a video about self-administration of insulin: Demonstrating a skill via video engages the cognitive and observational aspects of learning, but it does not ensure the client can perform the skill. Psychomotor learning requires active hands-on practice.

D. Observe the client practice self-monitoring of blood glucose levels: Observing and guiding the client as they perform the task addresses the psychomotor domain, which involves acquiring and demonstrating physical skills. Hands-on practice with feedback ensures the client develops competence in self-care activities.

Rationale for Correct Choices

• Thrombophlebitis: The client has a red streak along the vein, palpable cord, warmth, tenderness, and pain at the IV site, which are classic signs of thrombophlebitis. This condition involves inflammation of the vein often accompanied by a thrombus.
• Infection: Presence of purulent drainage at the IV insertion site along with fever (38.6° C / 101.5° F) indicates a local IV-related infection. Infection can occur secondary to thrombophlebitis or as an independent complication of IV therapy.

Rationale for Incorrect Choices

• Extravasation: Extravasation involves leakage of vesicant medication into surrounding tissue causing tissue damage, which is not described here.
• Infiltration: Infiltration is the leakage of nonvesicant IV fluid into surrounding tissue, typically causing swelling, pallor, and coolness, not the red streak and purulent drainage seen in this client.
• Circulatory overload: Circulatory overload presents with dyspnea, hypertension, and edema, none of which are noted in this client.
• Phlebitis: Phlebitis involves vein inflammation and pain but does not usually include purulent drainage. Thrombophlebitis better describes the combination of inflammation with a palpable cord.