A nurse in the emergency department is caring for a child who has a temperature of 39.1° C (102.4° F) and a suspected diagnosis of bacterial meningitis.
Which of the following actions should the nurse take first?

Prepare the child for a lumbar puncture.

Dim the lights in the child's room.

Administer an antipyretic to the child.

Implement droplet precautions for the child.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Implement droplet precautions for the child.

Choice A rationale:

Preparing the child for a lumbar puncture is important for diagnosing bacterial meningitis, but it is not the first action. Immediate infection control measures are more critical to prevent the spread of the disease.

Choice B rationale:

Dimming the lights can help reduce discomfort from photophobia, a common symptom of meningitis, but it is not the priority action when first addressing a suspected case of bacterial meningitis.

Choice C rationale:

Administering an antipyretic to reduce fever is important for comfort and to manage symptoms, but it does not address the immediate need to prevent the spread of infection.

Choice D rationale:

Implementing droplet precautions is the first action the nurse should take. Bacterial meningitis can be highly contagious, and droplet precautions help prevent the spread of the infection to other patients and healthcare workers.

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Correct Answer is D

Explanation

Choice A rationale:

Teaching the child about cast care is essential, but it is not the first priority. The immediate concern is addressing the child's comfort and preventing complications associated with the fractured right tibia. Teaching can come after addressing the acute needs.

Choice B rationale:

Petaling the edges of the cast might be necessary to prevent skin irritation, but it is not the first action to take. Elevating the child's leg is crucial to reduce swelling and promote blood circulation, which is the priority in this situation.

Choice C rationale:

Administering pain medication is important for the child's comfort, but it should not be the first action. Elevating the leg helps in reducing pain and swelling and promotes overall healing.

Choice D rationale:

Elevating the child's leg is the first action the nurse should take. Elevating the leg above heart level helps reduce swelling and improves blood circulation, which is crucial in the initial phase after applying the cast. This action can help prevent complications and promote the healing process. Once the leg is elevated, the nurse can then proceed with teaching the child about cast care and administering pain medication if needed.

A. Oliguria. B. Hypertension. C. Hyporeflexia. D. Hyperactive bowel sounds.

Correct Answer is C

Explanation

The correct answer is Choice C. Hyporeflexia.

Choice A rationale:

Oliguria, or reduced urine output, can be associated with dehydration or renal impairment, but it is not directly related to hypokalemia (low potassium levels). Hypokalemia primarily affects the muscles and heart rather than urine output.

Choice B rationale:

Hypertension is typically associated with high blood pressure and can be seen in conditions like hyperaldosteronism or Cushing's syndrome. However, it is not a direct result of hypokalemia. Low potassium levels usually lead to other cardiovascular issues such as arrhythmias, but not hypertension.

Choice C rationale:

Hyporeflexia, or decreased reflexes, is a common sign of hypokalemia. Potassium is essential for proper nerve and muscle function. When potassium levels are low, nerve impulses are slowed, leading to diminished reflexes. This symptom aligns with the preschooler's potassium level of 3.2 mEq/L, which is below the normal range.

Choice D rationale:

Hyperactive bowel sounds are not typically associated with hypokalemia. In fact, low potassium levels can lead to a reduction in gastrointestinal motility, potentially causing constipation or decreased bowel sounds, rather than hyperactivity.

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A nurse in the emergency department is caring for a child who has a temperature of 39.1° C (102.4° F) and a suspected diagnosis of bacterial meningitis. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a school-age child following the application of a cast to a fractured right tibia.Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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A nurse in the emergency department is caring for a child who has a temperature of 39.1° C (102.4° F) and a suspected diagnosis of bacterial meningitis.
Which of the following actions should the nurse take first?