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A nurse in an emergency department is caring for a school-age child.

Exhibits

The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.

Maintain NPO status.

Administer an antipyretic.

Initiate an infusion of IV fluids.

Administer a cleansing enema.

Prepare child and parents for ostomy placement.

Educate child and parents about plan of care.

Administer an analgesic.

Administer antibiotics.

Answer and Explanation

Correct Answer : A,B,C,F,G,H

A. Maintain NPO status. The child is at risk for surgery, and maintaining NPO status reduces the risk of aspiration.
B. Administer an antipyretic. Reducing fever can improve comfort and decrease metabolic demand.
C. Initiate an infusion of IV fluids. IV fluids prevent dehydration, especially since the child has had poor oral intake and diarrhea.
D. Administer a cleansing enema. An enema is contraindicated as it may worsen abdominal inflammation or cause perforation.
E. Prepare child and parents for ostomy placement. While surgery may be needed, an ostomy is not always required for appendicitis.
F. Educate child and parents about plan of care. Providing education helps reduce anxiety and ensures understanding of the interventions.
G. Administer an analgesic. Pain management is essential for comfort and reduces physiologic stress.
H. Administer antibiotics. Antibiotics are started preoperatively to manage infection or prevent complications if perforation is suspected.

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Correct Answer is D

Explanation

A. Protective environment: This is for immunocompromised clients, not infectious diseases like pertussis.
B. Airborne: Airborne precautions are used for diseases like tuberculosis, measles, or varicella, which spread through smaller airborne particles.
C. Contact: Contact precautions are for diseases transmitted via direct contact, such as MRSA or C. difficile, and are not appropriate for pertussis.
D. Droplet. Pertussis is transmitted through respiratory droplets, so droplet precautions (e.g., wearing a surgical mask and maintaining distance) are essential to prevent the spread.

A. Educate the infant's caregiver about the feeding. B. Flush the feeding tube before the feeding. C. Clarify the feeding prescription with the provider. D. Place a label on the feeding bag and tubing.

Correct Answer is C

Explanation

A. Educate the infant's caregiver about the feeding: While important, education should occur after ensuring the prescription is correct.
B. Flush the feeding tube before the feeding: This ensures patency but should only be done after verifying the prescription.
C. Clarify the feeding prescription with the provider. Bolus feedings are typically contraindicated with nasojejunal tubes because the jejunum cannot handle large volumes at once. Continuous feedings are usually prescribed. The prescription should be clarified before proceeding.
D. Place a label on the feeding bag and tubing: Labeling is necessary for safety but is not the priority when the prescription may be inappropriate.

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A nurse in an emergency department is caring for a school-age child. Exhibits The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.

Nursing Test Bank

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A nurse is admitting a child who has pertussis. Which of the following isolation precautions should the nurse initiate for the child?

Correct Answer is D

Explanation

A nurse is caring for an infant who is not tolerating enteral feeding through a nasogastric tube. The provider inserts a nasojejunal feeding tube and prescribes bolus enteral feedings. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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A nurse in an emergency department is caring for a school-age child.

Exhibits

The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.