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 B
Explanation
A. "I wish I knew what I did to cause my child to be sick." This statement reflects self-blame and guilt, which are signs of poor coping.
B. "I saw on the internet that there's a new treatment option." This demonstrates hope and proactive coping, as the guardian is seeking information and exploring options.
C. "I don't want my family to know about my child's diagnosis." Avoiding support from family may indicate denial or isolation, which are maladaptive coping strategies.
D. "I am not sure how to care for my dying child." Expressing uncertainty about caregiving suggests distress and a need for additional support and education, rather than positive adjustment.
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.
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