A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?
Apply topical calamine lotion.
Encourage oral fluids.
Administer acetaminophen as an antipyretic
Initiate transmission-based precautions
The Correct Answer is D
Initiate transmission-based precautions.
Rationale:
- B- Encouraging oral fluids is an important intervention for a child who has a fever, as it helps prevent dehydration and electrolyte imbalance. However, it is not the priority intervention, as it does not address the risk of infection transmission to other clients or staff.
- A - Applying topical calamine lotion may help soothe the itching and discomfort caused by the vesicles, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
- C - Administering acetaminophen as an antipyretic may help reduce the fever and provide symptomatic relief for the child, but it is not the priority intervention, as it does not prevent infection transmission or treat the underlying cause of the fever.
- D - Initiating transmission-based precautions is the priority intervention, as it protects other clients and staff from exposure to the infectious agent that causes the vesicles and fever. The nurse should wear gloves, gown, mask, and eye protection when caring for the child, and place them in a private room or cohort them with other clients who have similar symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Sodium level of 142 mEq/L is within the normal range (135-145 mEq/L) for adults. However, normal ranges for children might vary slightly, but 142 mEq/L is not indicative of dehydration on its own.
Choice B rationale:
Respiratory rate of 22/min is within the normal range for a 3-year-old child (20-30 breaths/min) This rate alone does not provide evidence of dehydration.
Choice C rationale:
Potassium level of 3.9 mEq/L is within the normal range (3.5-5.1 mEq/L) for children. Like sodium, normal ranges for potassium may differ slightly in pediatric patients, but 3.9 mEq/L is not alarming on its own.
Choice D rationale:
Heart rate of 148/min is elevated for a 3-year-old child. Tachycardia is a common sign of dehydration in pediatric patients. This increased heart rate indicates the body's compensatory mechanism to maintain cardiac output in response to decreased blood volume, a typical consequence of dehydration.
Correct Answer is D
Explanation
Choice A rationale:
Hyperthyroidism is not a contraindication for niacin use. Niacin is used to lower LDL cholesterol levels and has no specific contraindications related to thyroid disorders.
Choice B rationale:
Asthma is not a contraindication for niacin use. Niacin does not interact with asthma medications or worsen asthma symptoms, so it is not contraindicated in individuals with asthma.
Choice C rationale:
High blood pressure is not a contraindication for niacin use. In fact, niacin can help lower blood pressure and improve overall cardiovascular health. It is often prescribed to individuals with high blood pressure and elevated cholesterol levels.
Choice D rationale:
Active liver disease is a contraindication for niacin use. Niacin can cause liver damage, and individuals with active liver disease should avoid niacin therapy to prevent further harm to the liver. Monitoring liver function tests is crucial in patients taking niacin to ensure their liver health.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.