A nurse is admitting an 8-year-old child to the pediatric unit.
Select 1 condition and 1 client finding to fill in each blank in the following sentence.
The nurse should anticipate a provider's prescription for
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Initiating airborne precautions. The child’s symptoms (fever, headache, nausea, lethargy, irritability, nuchal rigidity, and elevated WBC count) suggest bacterial or viral meningitis, which requires airborne precautions if tuberculosis or certain viral causes are suspected.
WBC. The child's WBC count is elevated (14,000 mm³), indicating a possible infection, which supports the need for precautions to prevent transmission.
Administering potassium chloride. The child's potassium level (3.8 mEq/L) is within the normal range (3.4-4.7 mEq/L), so potassium replacement is unnecessary.
Pain level. While pain management is important, it does not directly relate to the need for airborne precautions.
Administering acyclovir. Acyclovir is an antiviral used to treat herpes infections, but there is no indication in the scenario that the child has a viral infection requiring acyclovir.
Lymph node findings. While cervical lymphadenopathy can occur with infections, it does not necessarily indicate the need for acyclovir.
Increasing environmental stimuli. The child is already lethargic and irritable, so reducing stimuli (not increasing) would be more appropriate.
Potassium level. The potassium level is normal and does not indicate a need for intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Use barrier ointments around the site." Barrier ointments (such as zinc oxide or petroleum-based products) help prevent skin irritation and breakdown caused by leakage of gastric contents.
B. "Cleanse the tube site with hydrogen peroxide." Hydrogen peroxide can be too harsh and may delay healing or cause irritation to the skin. Mild soap and water or saline are recommended for cleaning.
C. "Maintain tension between the tubing and the site." The tube should be secured but not under tension, as excessive pulling can cause discomfort, skin breakdown, or accidental dislodgement.
D. "Place a transparent occlusive dressing over the site." A gauze dressing may be used if there is drainage, but a transparent occlusive dressing can trap moisture, increasing the risk of infection.
Correct Answer is B
Explanation
A. "I will offer my child 20 grams of carbohydrates every 2 hours." During illness, children with diabetes should continue to eat, but it's more important to focus on maintaining adequate fluid intake and monitoring blood glucose levels. Carbohydrate intake may vary depending on the child's appetite and glucose levels, but 20 grams of carbohydrates every 2 hours may not be necessary for every child.
B. "I will increase the amount of fluids I offer my child." During illness, it is crucial to maintain hydration in children with diabetes to prevent dehydration, which can be exacerbated by fever, vomiting, or diarrhea. Fluids help maintain glucose stability and prevent complications such as diabetic ketoacidosis (DKA).
C. "I will withhold my child's dose of insulin when his appetite is poor.” Insulin should not be withheld even if the child's appetite is poor, as this can lead to hyperglycemia and diabetic ketoacidosis (DKA). Insulin needs should be adjusted based on blood glucose levels, not appetite.
D. "I will monitor my child's blood glucose levels every 8 hours." Blood glucose levels should be monitored more frequently, especially during illness. Typically, it's recommended to check every 2-4 hours to ensure the child’s blood glucose is within a safe range and to detect any changes that require adjustment in insulin therapy.
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