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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Heart rate is important to monitor but is not specific to the management of cystic fibrosis or the prescribed treatments mentioned in the exhibit. Monitoring heart rate is essential in various clinical situations, but it is not the focus here.
Choice B rationale:
WBC count, or white blood cell count, is a marker of infection or inflammation in the body. While it can be useful in assessing the overall health of a patient, it is not specific to cystic fibrosis or the prescribed treatments mentioned in the exhibit.
Choice C rationale:
HbA1c, or glycated hemoglobin, is a marker used in diabetes management to assess long-term blood sugar control. It is not relevant to cystic fibrosis or the medications prescribed in this case.
Choice D rationale:
Oxygen saturation is a crucial parameter to monitor in a child with cystic fibrosis, especially considering the respiratory complications associated with this condition. Low oxygen saturation levels can indicate respiratory distress, which needs prompt medical attention. Reporting any abnormal oxygen saturation values to the provider ensures timely intervention and appropriate management of the child's respiratory status.
Correct Answer is A
Explanation
Choice A rationale:
Increased respiratory rate is an expected finding in a severely dehydrated infant. Dehydration can lead to an increased breathing rate as the body tries to compensate for reduced blood volume and oxygenation. Respiratory rate may be rapid, and the infant may appear tachypneic. This compensatory mechanism helps maintain oxygen levels in the body.
Choice B rationale:
Capillary refill of 2 seconds is within the normal range and is not indicative of severe dehydration. Prolonged capillary refill time (>2 seconds) can be a sign of poor perfusion and dehydration, but a capillary refill time of 2 seconds is normal.
Choice C rationale:
Increased urine output is not an expected finding in severe dehydration. Dehydration leads to reduced urine output as the body tries to conserve fluids. In a dehydrated infant, urine output may be significantly decreased, indicating a lack of fluid intake and reduced renal perfusion.
Choice D rationale:
Hypertension is not a typical finding in severe dehydration. Dehydration often leads to decreased blood volume, which can result in low blood pressure rather than hypertension. Hypotension, not hypertension, is a common clinical manifestation of severe dehydration.
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