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 A
Explanation
Rationale:
A. An elevated creatinine level may indicate kidney dysfunction, which is a potential adverse effect of gentamicin therapy. It should be reported to the provider for further evaluation.
B. A creatinine level within the normal range is expected.
C. BUN within the normal range is expected.
D. BUN within the normal range is expected.
Correct Answer is D
Explanation
A. Rhinorrhea (runny nose) is a common symptom of respiratory syncytial virus (RSV) and may not require immediate reporting unless severe or accompanied by other concerning symptoms.
B. Pharyngitis (sore throat) is not typically considered a critical finding in RSV infection.
C. Coughing is a common symptom of RSV and is expected in infants with the infection. While coughing may require monitoring, it is not typically an immediate cause for concern unless severe.
D. Tachypnea (rapid breathing) is a concerning finding in infants with RSV infection, especially if it is severe or accompanied by signs of respiratory distress. Severe tachypnea may indicate worsening respiratory compromise and requires immediate attention and reporting to the healthcare provider for further evaluation and management.
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