A nurse is assessing a child who has been admitted with a urinary tract infection (UTI). Which of the following statements by the child's parent indicates a possible source of infection?
"She always wipes from front to back after using the toilet."
"She drinks plenty of water and cranberry juice every day."
"She likes to take bubble baths with her toys."
"She wears cotton underwear and loose-fitting pants."
The Correct Answer is C
Choice A reason: This is not a possible source of infection. Wiping from front to back after using
the toilet can prevent bacteria from entering the urinary tract and causing infection.
Choice B reason: This is not a possible source of infection. Drinking plenty of water and cranberry juice every day can help flush out bacteria from
the urinary tract and prevent infection.
Choice C reason: This is a possible source of infection. Taking bubble baths with toys can introduce bacteria into
the urinary tract and cause infection.
Choice D reason: This is not a possible source of infection. Wearing cotton underwear and loose-fitting pants can allow air circulation and prevent moisture buildup in
the genital area, which can reduce
the risk of infection.
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Correct Answer is D
Explanation
Choice A reason: This is not a priority intervention. The nurse should encourage oral fluids and soft foods to prevent dehydration and maintain nutrition, but this is not as important as monitoring the child for respiratory distress.
Choice B reason: This is an incorrect intervention. The nurse should not administer antitussive medication to a child who has pertussis, because it can suppress the cough reflex and increase the risk of mucus accumulation and airway obstruction.
Choice C reason: This is not a priority intervention. The nurse should provide humidified oxygen via nasal cannula to moisten the airways and ease breathing, but this is not as important as monitoring the child for respiratory distress.
Choice D reason: This is a priority intervention. The nurse should monitor the child for signs of respiratory distress, such as cyanosis, tachypnea, retractions, or nasal flaring, because pertussis can cause severe coughing spells that can interfere with breathing.
Correct Answer is A
Explanation
Choice A reason: Asking the patient to tell their name and date of birth is a way to confirm their identity and match it with the medication order. This is one of the steps of the "five rights" of medication administration, which are the right patient, the right drug, the right dose, the right route, and the right time.
Choice B reason: Asking the patient about their allergies or adverse reactions to medications is important, but it is not a way to ensure patient safety in terms of identification. The nurse should have checked the patient's allergy status before preparing the medication.
Choice C reason: Asking the patient how they feel today and if they have any pain or discomfort is a way to assess their condition and provide comfort measures, but it is not a way to ensure patient safety in terms of identification. The nurse should have done this assessment earlier in the shift or during the medication administration process.
Choice D reason: Asking the patient what is the name of the medication and why they are taking it is a way to educate them about their treatment and check their understanding, but it is not a way to ensure patient safety in terms of identification. The nurse should have done this education before or after giving the medication.
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