A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit.
Which of the following actions should the nurse take?
Administer aspirin to the child for fever
Use droplet precautions when caring for the child.
Assign the child to a negative air pressure room.
Assess the child for Koplik spots
The Correct Answer is C
This is because varicella, or chickenpox, is a highly contagious disease caused by the varicellazoster virus (VZV), which can spread through the air or by direct contact with the fluid from the blisters. A negative air pressure room prevents the air from the room from circulating to other areas of the hospital, reducing the risk of transmission to other patients and staff.
Choice A is wrong because aspirin should not be given to children with chickenpox, as it can cause a serious condition called Reye’s syndrome, which affects the brain and liver. Instead, acetaminophen can be used to reduce fever.
Choice B is wrong because droplet precautions are not enough to prevent the spread of chickenpox. Droplet precautions involve wearing a mask and gloves when in close contact with the patient, but they do not prevent the virus from traveling through the air. Airborne precautions, which include a negative air pressure room and wearing a respirator, are needed for chickenpox.
Choice D is wrong because Koplik spots are not a sign of chickenpox, but of measles, another viral infection that causes a rash. Chickenpox causes an itchy rash with small, fluid-filled blisters that crust over.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.
This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.
Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.
The nurse should assess this client first and notify the provider.
Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.
The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.
The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.
Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.
The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.
This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.
Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.
The nurse should assess this client first and notify the provider.
Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.
The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.
The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.
Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.
Correct Answer is ["B","C"]
Explanation
The correct answers are B and C.
Choice A Reason: Transferring a client who is receiving radiation therapy involves understanding the precautions and care associated with radiation, which may be beyond the training of assistive personnel (AP). Radiation therapy clients may have specific safety and transport protocols that require the expertise of licensed nursing staff.
Choice B Reason: Measuring vital signs for a client who requires contact precautions is a task that can be delegated to AP. Assistive personnel can be trained in infection control procedures and the use of personal protective equipment (PPE), making them capable of measuring vital signs while adhering to contact precautions.
Choice C Reason: Recording urine output for a client who has a suprapubic catheter can be delegated to AP. This task involves measuring and documenting a quantifiable data point, which does not require the clinical judgment of a nurse. AP can be trained to accurately measure and record urine output.
Choice D Reason: Planning care for a client who has dysphagia is a complex task that involves assessment and clinical judgment, which are responsibilities of the licensed nurse. Dysphagia can have serious complications, and care plans must be tailored to each client’s needs, requiring the expertise of a nurse.
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