A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

Monitor the child's cardiac status.

Give scheduled doses of acetaminophen every 6 hr.

Provide stimulation with children of the same age in the play room.

Administer antibiotics via intermittent IV bolus for 24 hr.

Answer and Explanation

The Correct Answer is A

A.   Kawasaki disease involves inflammation of the blood vessels and can lead to serious cardiac complications, including coronary artery aneurysms. Monitoring cardiac status is essential to detect and manage these risks.
B.   While managing fever is a part of treating Kawasaki disease, acetaminophen is typically used as needed rather than on a strict schedule unless fever is persistent.
C.   During the acute phase of Kawasaki disease, children often feel very irritable and unwell; large group activities may be overwhelming and inappropriate.
D.   Kawasaki disease is not caused by a bacterial infection, and antibiotics are not part of the treatment. Instead, treatment usually involves high-dose aspirin and intravenous immunoglobulin.

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Correct Answer is C

Explanation

A: Percussion should be performed with a cupped hand to provide effective airway clearance, not with a flat hand.
B: Postural drainage is typically performed multiple times per day to help clear secretions from the lungs in cystic fibrosis.
C: Postural drainage is often performed before meals to minimize the risk of vomiting due to manipulation of the abdomen.
D: Bronchodilators are not typically administered after postural drainage; they are used to help open the airways before the procedure.

A. "I should assess the client's skin integrity every 8 hours while in mechanical restraints." B. "I should visually monitor the client continuously when in mechanical restraints." C. "I should ask the provider to write a prescription for mechanical restraints as needed." D. "I should expect the provider to evaluate the client within 4 hours of restraint application."

Correct Answer is B

Explanation

A. Skin integrity should be assessed more frequently, generally every 2 hours.

B. Continuous visual monitoring is required to ensure the safety and well-being of a client who is in mechanical restraints, to respond promptly to any distress or complications.
C. Restraints should be a last resort and not prescribed as needed.

D. The provider should evaluate the client sooner, typically within 1 hour of applying restraints.

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A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

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