A nurse is planning care for a child who has varicella.
Which of the following interventions should the nurse plan to include?
Initiate airborne precautions.
Provide the child with a warm blanket.
Assess the oral cavity for Koplik spots.
Administer aspirin for fever.
The Correct Answer is A
Choice A rationale:
Varicella (chickenpox) is highly contagious and spreads through the air via respiratory droplets. Initiating airborne precautions, such as wearing masks and isolating the patient in a negative pressure room, helps prevent the spread of the virus to other patients and healthcare workers.
Choice B rationale:
Providing a warm blanket is a comfort measure and does not address the contagious nature of varicella. While keeping the child comfortable is important, preventing the spread of the infection to others is a higher priority.
Choice C rationale:
Koplik spots are small, white spots with blue or red centers that can appear on the oral mucosa in individuals with measles. Varicella does not cause Koplik spots; this finding is specific to measles. Therefore, assessing for Koplik spots is not relevant in the context of varicella.
Choice D rationale:
Administering aspirin to a child with varicella is contraindicated due to the risk of Reye's syndrome, a potentially fatal condition characterized by acute brain and liver damage. Acetaminophen is the preferred antipyretic for managing fever in children with varicella.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer is D. Oxygen saturation. The nurse should report the low oxygen saturation of 92% on room air to the provider, as this indicates hypoxemia and respiratory distress in a child with cystic fibrosis. The normal range for oxygen saturation is 95% to 100%¹. Hypoxemia can lead to complications such as pulmonary hypertension, cor pulmonale, and respiratory failure².
A. Heart rate is not the correct answer. The heart rate of 98 beats/min is normal high, but not alarming for a child with cystic fibrosis. The normal range for heart rate in school-age children is 60 to 100 beats/min³. A higher heart rate may be due to fever, infection, dehydration, or anxiety⁴.
B. WBC count is not the correct answer. The WBC count of 10,000/mm3 is within the normal range of 5,000 to 10,000/mm3⁵. A high WBC count may indicate infection or inflammation, which are common in cystic fibrosis⁶.
C. HbA1c is not the correct answer. The HbA1c of 6.5% is borderline for diabetes, but not an urgent finding. The normal range for HbA1c is 4% to 5.6%, and a level of 6.5% or higher indicates diabetes⁷. Cystic fibrosis-related diabetes (CFRD) is a common complication of cystic fibrosis, affecting about 30% of adults with the condition⁸. CFRD requires regular monitoring and treatment with insulin⁹..
Correct Answer is B
Explanation
Choice A rationale:
Rhinorrhea (runny nose) is a common symptom of respiratory syncytial virus (RSV) infection and is not a cause for immediate concern. It is often accompanied by other upper respiratory symptoms in infants and young children.
Choice B rationale:
Tachypnea (rapid breathing) is a concerning sign in infants with RSV infection. Rapid breathing can indicate respiratory distress and difficulty in oxygen exchange, which is common in severe RSV cases. Infants with RSV may exhibit rapid, shallow breathing, flaring nostrils, and chest retractions as they struggle to breathe.
Choice C rationale:
Pharyngitis (sore throat) can be a symptom of RSV infection but is not a critical finding that requires immediate reporting to the provider. Respiratory distress and signs of respiratory failure, such as tachypnea, are more urgent concerns.
Choice D rationale:
Coughing is a common symptom of RSV infection and may not necessarily warrant immediate reporting, especially if the cough is mild and not accompanied by severe respiratory distress. However, persistent coughing, especially if it leads to difficulty in breathing, should be assessed promptly.
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