A nurse is planning care for a child who has varicella. Which of the following interventions should the nurse plan to include?
Provide the child with a warm blanket.
Assess the oral cavity for Koplik spots.
Administer aspirin for fever.
Initiate airborne precautions.
The Correct Answer is D
Rationale:
A. Providing the child with a warm blanket can help keep the child comfortable during the course of the illness but initiating airborne precautions is best intervention required.
B. Assessing the oral cavity for Koplik spots is not relevant for varicella, as Koplik spots are associated with measles.
C. Administering aspirin for fever is contraindicated in children with varicella due to the risk of Reye's syndrome.
D. The nurse should initiate airborne precautions, which include placing the child in a private room with negative air pressure, wearing a mask or respirator when entering the room, and limiting visitors and staff exposure. Airborne precautions prevent the transmission of varicella through small droplets that can remain suspended in the air for long periods of time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Offering sips of water 4 hours following surgery may be too early and could increase the risk of postoperative complications such as nausea and vomiting.
B. Assisting the adolescent to ambulate 12 hours following surgery may be too early depending on the surgical procedure and the adolescent's condition.
C. Maintaining the head of the bed at a 30° angle is incorrect because this position increases pressure on the spinal cord and can cause complications.
D. Logrolling the adolescent every 2 hours prevents spinal injury and promotes healing by keeping the spine in alignment
Correct Answer is C
Explanation
Rationale:
A. Checking the newborn's eyes every 8 hours is not necessary for the management of hyperbilirubinemia or phototherapy.
B. Placing mittens on the newborn's hands is unrelated to the management of hyperbilirubinemia or phototherapy.
C. Monitoring the newborn's temperature every 2 hours is essential during phototherapy because infants are at risk of hypothermia due to increased heat loss from the lights.
D. Applying lotion to the newborn's skin is not recommended during phototherapy as it can interfere with the effectiveness of the lights.
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