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?

Encourage oral fluids.

Administer acetaminophen as an antipyretic.

Apply topical calamine lotion.

Initiate transmission-based precautions.

Answer and Explanation

The Correct Answer is D

A. 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.
C. 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.
B. 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.

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Correct Answer is B, A, D, C

Explanation

B. Inspection is the first step in an abdominal assessment because it allows the nurse to observe the shape, size, symmetry, contour, and movement of the abdomen. Inspection also helps to identify any abnormalities such as scars, lesions, masses, or distension.

A. Auscultation is the second step in an abdominal assessment because it allows the nurse to listen to the bowel sounds and vascular sounds of the abdomen. Auscultation should be performed before palpation or apercussion because these maneuvers could alter the sounds.

D. Percussion is the third step in an abdominal assessment because it allows the nurse to elicit sounds from different organs and structures in the abdomen. Percussion helps to determine the size, location, density, and consistency of the organs and to detect any fluid or air accumulation.

C. Palpation is the last step in an abdominal assessment because it allows the nurse to feel the texture, temperature, tenderness, and masses of the abdomen. Palpation should be performed gently and carefully to avoid causing pain or injury to the client.

A. Remove indwelling urinary catheter when no longer indicated. B. Elevate affected limb at chest level. C. Assist the adolescent with ambulation from bed to chair. D. Perform neurovascular assessments every hour. E. Apply warm packs to right extremity for the first 24hrs

Correct Answer is ["A","C","D"]

Explanation

A. Remove indwelling urinary catheter when no longer indicated: This action prevents urinary tract infections and promotes bladder function.

B. Elevate affected limb at chest level: This action is contraindicated because it increases venous pressure and edema in the affected extremity, which could compromise blood flow and nerve function.
C. Assist the adolescent with ambulation from bed to chair: This action prevents complications such as deep vein thrombosis, pulmonary embolism, pneumonia, and constipation by enhancing circulation, respiration, and bowel motility.
D. Perform neurovascular assessments every hour: This action monitors for signs of impaired blood flow or nerve function in the affected extremity, such as changes in color, temperature, sensation, movement, or pulse.
E. Apply warm packs to right extremity for the first 24hrs: This action is contraindicated because it increases blood flow and edema in the affected extremity, which could compromise blood flow and nerve function.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take.

Correct Answer is B, A, D, C

Explanation

Correct Answer is ["A","C","D"]

Explanation

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