Exhibits
A nurse in an emergency department is caring for a 3-month-old infant. Which of the following actions should the nurse take?
Administer ceftriaxone.
Administer pneumococcal conjugate vaccine.
Initiate serum glucose testing every 1 hr.
Initiate neutropenic precautions.
The Correct Answer is A
A. Given the cloudy appearance of the cerebrospinal fluid (CSF) and elevated white blood cell count (WBC) in the CSF, there may be an indication of meningitis.
Ceftriaxone is a broad-spectrum antibiotic commonly used to treat bacterial meningitis. Therefore, administering ceftriaxone would be an appropriate action.
B. While vaccines are important for preventing infections, administering the pneumococcal conjugate vaccine is not the immediate priority in this scenario. The patient is already exhibiting signs of a potential infection, and treatment should focus on addressing the current condition first.
C. The infant's serum glucose level is low at 64 mg/dL (normal range: 60 to 100 mg/dL).
However, the primary concern at this moment appears to be the potential bacterial meningitis indicated by the cloudy CSF, elevated WBC count, and abnormal CSF glucose level. While monitoring serum glucose is important, it is not the most critical action in this case.
D. Neutropenic precautions are typically implemented to protect patients with low neutrophil counts (neutropenia) from acquiring infections. However, there is no indication of neutropenia in the provided diagnostic results. Additionally, the cloudy CSF and elevated WBC count suggest a possible bacterial infection rather than a neutropenic condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. Cyanosis can occur in children with heart failure due to inadequate oxygenation of tissues.
B. Weight gain or fluid retention is more common in children with heart failure.
C. Bounding pulses are more commonly associated with conditions such as hypertension or hyperthyroidism, rather than heart failure.
D. Dyspnea, or difficulty breathing, is a common symptom of heart failure due to fluid buildup in the lungs.
E. Tachycardia, or a rapid heart rate, can occur as a compensatory mechanism in response to decreased cardiac output in heart failure.
Correct Answer is C
Explanation
Rationale:
A. Storing opened vials of insulin for up to 60 days is incorrect. Insulin should be discarded after the manufacturer's recommended expiration date or within 28 days after opening, whichever comes first.
B. Physical therapy is not typically indicated as part of routine care for adolescents with type 1 diabetes mellitus. However, regular physical activity is encouraged for overall health and blood sugar management.
C. Consulting with a nutritionist is important for adolescents with type 1 diabetes mellitus to receive individualized meal planning guidance, carbohydrate counting education, and dietary recommendations to help manage blood sugar levels.
D. Monitoring capillary blood glucose daily is essential for adolescents with type 1 diabetes mellitus, but it is not the only recommendation. Comprehensive diabetes management includes multiple aspects such as insulin therapy, dietary modifications, physical activity, and regular monitoring of blood glucose levels.
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