A nurse is planning care for a child who has mumps. Which of the following instructions should the nurse include in the plan?
Initiate contact precautions.
Initiate standard precautions.
Initiate airborne precautions.
Initiate droplet precautions.
The Correct Answer is D
Choice A: Contact precautions are not necessary for a child who has mumps, as mumps is not transmitted by direct or indirect contact with the infected person or their environment. Contact precautions are used for infections that are spread by contact with skin, wounds, body fluids, or contaminated surfaces.
Choice B: Standard precautions are always used for any patient care, regardless of their diagnosis or infection status. Standard precautions include hand hygiene, use of personal protective equipment (PPE), safe injection practices, and proper disposal of waste and sharps. However, standard precautions alone are not sufficient for a child who has mumps, as mumps are transmitted by respiratory droplets.
Choice C: Airborne precautions are not necessary for a child who has mumps, as mumps are not transmitted by small particles that remain suspended in the air and can be inhaled by others. Airborne precautions are used for infections that are spread by airborne transmission, such as tuberculosis, measles, or chickenpox.
Choice D: Droplet precautions are required for a child who has mumps, as mumps are transmitted by large respiratory droplets that are expelled when the infected person coughs, sneezes, or talks. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, placing the patient in a private room or cohorts with other patients with the same infection, and limiting visitors and staff who are susceptible to the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Loosening restrictive clothing is not the priority action, but rather a secondary action for a child who is having a tonic-clonic seizure and vomiting. A tonic-clonic seizure is a type of seizure that involves the stiffening of muscles (tonic phase) followed by jerking movements (clonic phase). Loosening restrictive clothing can prevent injury or discomfort to the child during or after the seizure.
Choice B: Placing a pillow under the child's head is not the priority action, but rather an inappropriate action for a child who is having a tonic-clonic seizure and vomiting. A pillow under the head can obstruct the airway or cause aspiration of vomitus into the lungs. The nurse should remove any pillows or objects from around the head and neck area and support the head with their hands or on a flat surface.
Choice C: Clearing the area of hazards is not the priority action, but rather a secondary action for a child who is having a tonic-clonic seizure and vomiting. Clearing the area of hazards can prevent injury or harm to the child or others during or after the seizure. The nurse should remove any sharp, hard, or flammable objects from near or under the child and move any furniture or equipment away.
Choice D: Positioning the child side-lying is the priority action for a child who is having a tonic-clonic seizure and vomiting, as it can protect the airway and prevent aspiration of vomitus into the lungs. Aspiration can cause pneumonia, which is an infection of the lungs that can cause fever, cough, difficulty breathing, or death. The nurse should turn the child's head to one side and place them on their side with their knees bent and one arm under their head. The nurse should also suction any vomitus from their mouth and nose if needed.
Correct Answer is B
Explanation
Choice A reason: This choice is incorrect because taking glyburide with breakfast is not recommended for an adolescent who has type 1 diabetes mellitus. Glyburide is an oral hypoglycemic medication that lowers blood glucose levels by stimulating insulin secretion from the pancreas. It may be used for clients who have type 2 diabetes mellitus, but it does not work for clients who have type 1 diabetes mellitus or DKA.
Choice B reason: This choice is correct because obtaining an influenza vaccine annually is recommended for an adolescent who has type 1 diabetes mellitus. The influenza vaccine is a vaccine that protects against influenza, a viral infection that affects the respiratory system. It may prevent or reduce the severity of influenza and its complications, such as pneumonia or sepsis. It is recommended for everyone who is 6 months or older, especially those who have chronic conditions such as diabetes mellitus that increase their risk of influenza-related complications.
Choice C reason: This choice is incorrect because administering glucagon for hyperglycemia is not indicated for an adolescent who has type 1 diabetes mellitus. Glucagon is a hormone that raises blood glucose levels by stimulating glycogen breakdown in the liver. It may be used for clients who have hypoglycemia, which is a condition in which blood glucose levels are lower than normal (less than 70 mg/dL). It may cause symptoms such as sweating, trembling, confusion, or loss of consciousness. However, in type 1 diabetes mellitus, hyperglycemia (high blood glucose levels) rather than hypoglycemia is more likely to occur due to insulin deficiency or resistance.
Choice D reason: This choice is incorrect because injecting insulin in the deltoid muscle is not an optimal method for an adolescent who has type 1 diabetes mellitus. Insulin is a hormone that lowers blood glucose levels by facilitating glucose uptake into the cells. It may be administered by injection or infusion, and it may vary in onset, peak, and duration of action. The preferred sites for insulin injection are the abdomen, the thighs, the buttocks, or the upper arms, as they have more subcutaneous fat and less muscle tissue. Injecting insulin into the deltoid muscle may cause faster absorption and shorter duration of action, which can affect blood glucose control and increase the risk of hypoglycemia.
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