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.
Initiate serum glucose testing every 1 hr.
Administer pneumococcal conjugate vaccine.
Initiate neutropenic precautions.
The Correct Answer is A
A. Administer ceftriaxone. Correct. The CSF analysis shows elevated pressure, cloudy appearance, increased WBC count, elevated protein, and decreased glucose levels, which are indicative of bacterial meningitis. Ceftriaxone is a broad-spectrum antibiotic that is commonly used to treat bacterial meningitis, especially in infants and young children. Immediate administration of antibiotics is crucial to treat the infection and prevent complications.
Other Options:
B. Initiate serum glucose testing every 1 hr. Incorrect. Although the CSF glucose is low, this finding is associated with bacterial meningitis rather than a primary glucose metabolism issue in this context. Regular glucose monitoring every 1 hour is not warranted for managing meningitis. The priority is to address the underlying infection with antibiotics.
C. Administer pneumococcal conjugate vaccine. Incorrect. Vaccination is a preventive measure, not an immediate treatment for an ongoing infection. This infant likely already needs treatment for a current infection, and vaccination would be inappropriate at this stage.
D. Initiate neutropenic precautions.Incorrect. Neutropenic precautions are used for patients with significantly low neutrophil counts to prevent infection. The CSF results do not suggest neutropenia; instead, they suggest an active bacterial infection. The focus should be on treating the infection, not on precautions for low neutrophil count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer antispasmodics: Antispasmodics are not typically used for vaso-occlusive crisis pain, which is usually due to ischemia and not muscle spasms.
B. Apply ice to joints: Applying ice is not recommended as it can cause vasoconstriction, worsening the sickling of cells and the pain associated with a vaso-occlusive crisis. Heat application is more appropriate to promote circulation.
C. Initiate IV fluids: Correct. Hydration is a key intervention in managing a vaso-occlusive crisis because it helps to decrease the viscosity of the blood and prevent further sickling of cells.
D. Assess for hyperkalaemia: While it is important to monitor electrolyte levels, hyperkalaemia is not directly associated with a vaso-occlusive crisis. The primary focus should be on pain management and hydration.
Correct Answer is C
Explanation
A. "Leads will be placed on your child's back prior to the procedure." ECG leads are typically placed on the chest, arms, and legs, not on the back. This statement would be inaccurate and could confuse the parent.
B. "This procedure will take at least 30 minutes to complete." An ECG is a relatively quick procedure, usually taking about 5 to 10 minutes. This statement is misleading regarding the duration of the test.
C. "Your child can rest on your lap during the procedure." Allowing the child to rest on the parent’s lap can help the child feel more secure and calm during the procedure, which can help in obtaining an accurate ECG reading. This statement provides accurate and helpful information.
D. "An alarm will sound if your child has an abnormal heart rhythm."An ECG machine does not have an alarm for abnormal rhythms during the test. It simply records the heart's electrical activity for later interpretation by a healthcare provider.
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