A nurse is admitting a school-age child who has osteomyelitis. Which of the following actions should the nurse take first?
Obtain a blood culture.
Request a referral for physical therapy.
Administer IV antibiotics.
Record intake and output.
The Correct Answer is A
A. Obtain a blood culture. The first action is to obtain a blood culture to identify the causative organism before starting antibiotic therapy. This ensures that the appropriate antibiotic is selected.
B. Request a referral for physical therapy. Physical therapy may be needed later, but it is not the priority during admission.
C. Administer IV antibiotics. Antibiotics should be given after obtaining a blood culture to avoid altering the test results.
D. Record intake and output. While monitoring fluid balance is important, it is not the priority action during admission.
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Related Questions
Correct Answer is A
Explanation
A. Use simple diagrams to explain the procedure. Children benefit from visual aids to help them understand medical procedures. Using simple diagrams can help the child visualize what will happen during the tonsillectomy in a non-threatening way and make the process less intimidating.
B. Indicate on a stuffed animal where the procedure will be performed. While a stuffed animal might be useful for younger children, a 9-year-old is more likely to benefit from a visual aid that is more aligned with their cognitive and developmental level. Simple diagrams or pictures would be more appropriate for this age group.
C. Provide teaching immediately before the procedure. It is more effective to provide teaching well before the procedure to allow the child time to process and ask questions. Immediate preoperative teaching might lead to increased anxiety and may not allow enough time for the child to fully understand.
D. Discuss the benefits of the procedure. While it is important to acknowledge the purpose of the procedure, focusing on the benefits alone might not address the child's concerns and anxieties about the procedure. Explaining the procedure in a straightforward and understandable manner, without overemphasizing the benefits, is usually more effective in reducing anxiety.
Correct Answer is A
Explanation
A. Give the child 3 to 6 oz of orange juice. The child's altered mental status, diaphoresis, and tremors indicate hypoglycemia. The best initial treatment for mild to moderate hypoglycemia is a fast-acting carbohydrate, such as orange juice (3 to 6 oz) to rapidly raise blood glucose levels.
B. Give the child a candy bar. While candy contains sugar, it also contains fat, which slows glucose absorption, delaying the correction of hypoglycemia.
C. Administer glucagon to the vastus lateralis. Glucagon is used for severe hypoglycemia (e.g., unconsciousness or seizures), not for mild to moderate symptoms.
D. Administer D5W intravenous fluids. IV dextrose is used in severe cases where the child is unconscious or unable to take oral glucose. Since this child is conscious, oral treatment is preferred.
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