A nurse is caring for a school-age child who has pertussis. Which of the following actions should the nurse take?
Place the child in a protected environment for 48 hr
Administer the pertussis vaccine.
Report the diagnosis to the public health department.
Restrict oral fluids to 500 mL per day.
The Correct Answer is C
A. Place the child in a protected environment for 48 hr: While isolation might be implemented, 48 hours is not a typical timeframe for pertussis. The contagious period can last for weeks.
B. Administer the pertussis vaccine: The pertussis vaccine is for prevention, not treatment of an active case.
C. Report the diagnosis to the public health department. Pertussis, also known as whooping cough, is a highly contagious respiratory illness. Reporting the case to the public health department allows them to track the spread of the disease and take steps to prevent further outbreaks
D. Restrict oral fluids to 500 mL per day. Restricting fluids can worsen dehydration, especially in a child with a respiratory illness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Auscultate the abdomen for at least 1 min if bowel sounds are absent. This is an appropriate action. Absence of bowel sounds can indicate a serious condition, so the nurse should auscultate for at least 1 minute to confirm their absence. However, it is generally recommended to listen for up to 5 minutes before concluding that bowel sounds are absent.
B. Use the bell stethoscope to auscultate breath sounds. The diaphragm of the stethoscope, not the bell, is typically used to auscultate breath sounds because it is better at picking up higher-pitched sounds like those of the lungs.
C. Check visual acuity by using the tumbling E eyechart. The tumbling E chart is appropriate for pre-schoolers who may not know the alphabet. This chart helps assess visual acuity in young children by having them identify the direction of the E's legs.
D. Place hand on the pre-schooler’s abdomen to determine respiratory rate. Placing a hand on the abdomen can help in counting the respiratory rate in infants and very young children who are diaphragmatic breathers, but for pre-schoolers, it is typically easier and more accurate to count respirations by observing the chest rise.
Correct Answer is C
Explanation
A. Bradycardia: Bradycardia (a slow heart rate) is not typically associated with heart failure. Heart failure usually leads to increased heart rate (tachycardia) as the heart attempts to compensate for poor cardiac output.
B. Increased appetite: Increased appetite is not commonly seen in heart failure. In fact, children with heart failure often have poor appetite and may experience difficulty eating due to fatigue and shortness of breath.
C. Tachypnea: Correct. Tachypnea is a common manifestation of heart failure as the body attempts to increase oxygen intake due to decreased cardiac output and poor perfusion.
D. Tremors: Tremors are not typically associated with heart failure. They are more commonly related to neurological or metabolic conditions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.