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.
Restrict oral fluids to 500 mL per day.
Report the diagnosis to the public health department.
The Correct Answer is D
A. Placing the child in a protected environment for 48 hours is not a necessary measure for managing pertussis. Pertussis is transmitted through respiratory droplets, and standard precautions are typically sufficient.
B. Administering the pertussis vaccine is a preventive measure, but it is not a treatment for an active infection. In this case, the child already has pertussis, so administering the vaccine will not address the current illness.
C. Restricting oral fluids to 500 mL per day is not a recommended intervention for pertussis. Maintaining hydration is important, and fluid intake should be based on the child's needs.
D. This is the correct action. Reporting the diagnosis of pertussis to the public health department is a crucial step in preventing the spread of the disease. It allows for contact tracing and appropriate public health measures to be implemented to limit further
transmission.
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Related Questions
Correct Answer is D
Explanation
- A: Tighten the screws on the halo device one-quarter turn every 48 hr.
- Rationale: This action is incorrect because the screws on a halo device should not be adjusted by the nurse. The screws are typically set and secured by a healthcare provider, and any adjustments can compromise the integrity of the device and the stability of the cervical spine.
- B: Assess the pin sites for infection once every other day.
- Rationale: While it is important to monitor the pin sites for signs of infection, doing so once every other day may not be sufficient. Pin sites should be assessed at least once per shift to ensure early detection and management of any potential infection.
- C: Encourage flexion and extension of the neck.
- Rationale: This action is contraindicated for a client with a halo vest. The purpose of the halo vest is to immobilize the cervical spine to promote healing. Encouraging neck movement could cause further injury or delay healing.
- D: Reposition the client using a turning sheet.
- Rationale: This is the correct action. Using a turning sheet helps to reposition the client safely and effectively without exerting unnecessary pressure on the cervical spine. It also aids in preventing pressure ulcers and promotes comfort for the client.
Correct Answer is D
Explanation
A. Dark brown blood in emesis is expected postoperatively due to swallowed blood and does not require immediate intervention.
B. A mild fever (38°C or 100°F) can occur postoperatively and is not an emergency.
C. Pain is expected after a tonsillectomy and should be managed but does not require immediate intervention.
D. Frequent swallowing may indicate active bleeding from the surgical site, which requires immediate assessment and intervention.
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