Exhibits
A nurse in an emergency department is caring for a 3-month-old infant. Which of the following actions should the nurse take?
Administer ceftriaxone.
Administer pneumococcal conjugate vaccine.
Initiate serum glucose testing every 1 hr.
Initiate neutropenic precautions.
The Correct Answer is A
A. Given the cloudy appearance of the cerebrospinal fluid (CSF) and elevated white blood cell count (WBC) in the CSF, there may be an indication of meningitis.
Ceftriaxone is a broad-spectrum antibiotic commonly used to treat bacterial meningitis. Therefore, administering ceftriaxone would be an appropriate action.
B. While vaccines are important for preventing infections, administering the pneumococcal conjugate vaccine is not the immediate priority in this scenario. The patient is already exhibiting signs of a potential infection, and treatment should focus on addressing the current condition first.
C. The infant's serum glucose level is low at 64 mg/dL (normal range: 60 to 100 mg/dL).
However, the primary concern at this moment appears to be the potential bacterial meningitis indicated by the cloudy CSF, elevated WBC count, and abnormal CSF glucose level. While monitoring serum glucose is important, it is not the most critical action in this case.
D. Neutropenic precautions are typically implemented to protect patients with low neutrophil counts (neutropenia) from acquiring infections. However, there is no indication of neutropenia in the provided diagnostic results. Additionally, the cloudy CSF and elevated WBC count suggest a possible bacterial infection rather than a neutropenic condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Missing front deciduous teeth are a common occurrence during childhood and are not necessarily indicative of physical abuse.
B. Weight in the 45th percentile is within the normal range for a 7-year-old and does not indicate physical abuse.
C. Bruising around the wrists can be a sign of physical abuse, especially if it appears in patterns consistent with being restrained.
D. Abrasions on the knees are common in children who are active and are not necessarily indicative of physical abuse.
Correct Answer is D
Explanation
Rationale:
A. Disseminated intravascular coagulation (DIC) is associated with consumption of clotting factors, leading to prolonged clotting times, such as increased prothrombin time (PT) and activated partial thromboplastin time (aPTT), rather than decreased.
B. DIC does not typically cause an increase in hemoglobin (Hgb) levels; in fact, it may lead to anemia due to blood loss and consumption of clotting factors.
C. DIC does not typically cause an increase in red blood cell (RBC) count; if anything, it can lead to anemia due to blood loss.
D. DIC is characterized by widespread activation of coagulation, leading to consumption of platelets and decreased platelet count, which can result in bleeding tendencies.
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