A nurse is caring for a 4-year-old child who has been diagnosed with rotavirus gastroenteritis. Which of the following actions should the nurse take? (Select all that apply.)

Administer oral rehydration solution as prescribed.

Monitor the child's weight and intake and output.

Isolate the child from other children in the unit.

Collect stool specimens for culture and sensitivity.

Teach the parents about proper hand hygiene.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason: This is a correct action. The nurse should administer oral rehydration solution as prescribed to prevent dehydration and electrolyte imbalance.

Choice B reason: This is a correct action. The nurse should monitor the child's weight and intake and output to assess fluid status and hydration level.

Choice C reason: This is a correct action. The nurse should isolate the child from other children in the unit to prevent transmission of rotavirus, which is highly contagious.

Choice D reason: This is an incorrect action. The nurse does not need to collect stool specimens for culture and sensitivity, because rotavirus gastroenteritis is diagnosed by antigen detection tests or polymerase chain reaction (PCR) tests.

Choice E reason: This is a correct action. The nurse should teach the parents about proper hand hygiene to prevent infection and cross-contamination.

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Correct Answer is B

Explanation

Choice A reason: Contact isolation is used for patients who have infections that can be spread by direct or indirect contact with the patient or their environment. Pertussis is not transmitted by contact, but by respiratory droplets.

Choice B reason: Droplet isolation is used for patients who have infections that can be spread by large respiratory droplets that are generated by coughing, sneezing, or talking. Pertussis is transmitted by respiratory droplets, so droplet isolation is appropriate.

Choice C reason: Airborne isolation is used for patients who have infections that can be spread by small airborne particles that can remain suspended in the air and travel over long distances. Pertussis is not transmitted by airborne particles, but by respiratory droplets.

Choice D reason: Protective isolation is used for patients who have compromised immune systems and are at risk of acquiring infections from others. Pertussis does not require protective isolation, as it does not pose a threat to immunocompromised patients.

A. Encourage oral fluids and soft foods. B. Administer antitussive medication as needed. C. Provide humidified oxygen via nasal cannula. D. Monitor the child for signs of respiratory distress.

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.

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A nurse is caring for a 4-year-old child who has been diagnosed with rotavirus gastroenteritis. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

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