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 C
Explanation
A. Asking the child's parent to leave the room during the procedure may increase the child's anxiety and make the procedure more traumatic.
B. Performing the procedure in the unit's playroom may not provide the necessary equipment and sterile environment required for a venipuncture.
C. Applying a topical anesthetic cream helps reduce pain and discomfort during the venipuncture, promoting atraumatic care.
D. Explaining the procedure in detail to the child 3 hours prior to the procedure may increase anxiety and anticipation, making the procedure more traumatic.
Correct Answer is D
Explanation
A. Visual acuity should be assessed for each eye separately first, then both eyes together to detect any differences between the eyes.
B. The nurse should position the child 3 meters (10 feet) from the chart and ask the child to point in the direction of the open end of each letter.
C. If the child wears glasses, they should be tested with and without their glasses to assess visual acuity accurately.
D. A tumbling E chart, where the child identifies the direction of the E (up, down, left, or right), is commonly used for assessing visual acuity in young children who may not yet know letters.
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