A nurse is assisting with the admission of a child who has measles. Which of the following isolation precautions should the nurse initiate?
Contact
Airborne
Protective environment
Droplet
The Correct Answer is B
Choice A: Contact isolation is not appropriate for a child who has measles, which is a highly contagious viral infection that causes fever, rash, cough, runny nose, and red eyes. Contact isolation is used for patients who have infections that can be spread by direct or indirect contact with the patient or their environment, such as wound infections, scabies, or Clostridioides difficile. Contact isolation requires wearing gloves and gowns and using dedicated equipment.
Choice B: Airborne isolation is appropriate for a child who has measles, as it is used for patients who have infections that can be spread by small droplets that can remain suspended in the air and travel over long distances, such as tuberculosis, chickenpox, or measles. Airborne isolation requires wearing a respirator mask and placing the patient in a negative pressure room with the door closed.
Choice C: Protective environment isolation is not appropriate for a child who has measles, as it is used for patients who have compromised immune systems and are at high risk of acquiring infections from others, such as transplant recipients, cancer patients, or patients receiving immunosuppressive therapy. Protective environment isolation requires wearing gloves, gowns, masks, and eye protection and placing the patient in a positive pressure room with high-efficiency particulate air (HEPA) filters.
Choice D: Droplet isolation is not appropriate for a child who has measles, as it is used for patients who have infections that can be spread by large droplets that can travel up to 6 feet from the source, such as influenza, pertussis, or meningitis. Droplet isolation requires wearing a surgical mask and eye protection and placing the patient in a private room or cohorting with other patients with the same infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: This information is incorrect, as the first dose of the diphtheria, tetanus, pertussis (DTaP) vaccine is usually given at 2 months of age, not 2 weeks. The DTaP vaccine protects against three serious bacterial diseases that can cause respiratory infections, nerve damage, or death. The DTaP vaccine is given in five doses at 2, 4, 6, 15 to 18 months, and 4 to 6 years of age.
Choice B: This information is correct, as the first dose of the hepatitis B vaccine is usually given within 24 hours of birth or prior to discharge from the hospital. The hepatitis B vaccine protects against a viral infection that can cause liver inflammation, cirrhosis, or cancer. The hepatitis B vaccine is given in three doses at birth, 1 to 2 months, and 6 to 18 months of age.
Choice C: This information is incorrect, as the first dose of the measles, mumps, rubella (MMR) vaccine is usually given at 12 to 15 months of age, not 6 months. The MMR vaccine protects against three viral diseases that can cause fever, rash, swelling of glands, or complications such as pneumonia, encephalitis, or deafness. The MMR vaccine is given in two doses at 12 to 15 months and 4 to 6 years of age.
Choice D: This information is incorrect, as the first dose of the pneumococcal conjugate (PCV13) vaccine is usually given at 2 months of age, not on the first birthday. The PCV13 vaccine protects against a bacterial infection that can cause pneumonia, meningitis, or sepsis. The PCV13 vaccine is given in four doses at 2, 4, 6, and 12 to 15 months of age.
Correct Answer is B
Explanation
Choice A: A heart rate of 72/min is within the normal range for an adolescent, which is 60 to 100 beats per minute. A heart rate of 72/min does not indicate any signs of shock, hemorrhage, or cardiac injury. Therefore, this finding is not the nurse's priority.
Choice B: A blood pressure of 84/52 mm Hg is below the normal range for an adolescent, which is 110 to 120/70 to 80 mm Hg. A blood pressure of 84/52 mm Hg indicates hypotension, which can be a sign of shock, hemorrhage, or internal organ damage. Hypotension can lead to decreased tissue perfusion, organ failure, or death. Therefore, this finding is the nurse's priority and requires immediate intervention.
Choice C: An abdominal pain rated 4 on a scale of 0 to 10 is a moderate level of pain that can indicate inflammation, injury, or infection in the abdomen. However, pain is a subjective symptom that may vary depending on the individual and the severity of the condition. Pain can also be managed with analgesics or other measures. Therefore, this finding is not the nurse's priority.
Choice D: A respiratory rate of 20/min is within the normal range for an adolescent, which is 12 to 20 breaths per minute. A respiratory rate of 20/min does not indicate any signs of respiratory distress, hypoxia, or pulmonary injury. Therefore, this finding is not the nurse's priority.
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