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 B
Explanation
A. A temperature of 37.2°C (99°F) is slightly elevated but not a major concern post-surgery.
B. Urine output 256 mL over 8 hr: In a child with nephrotic syndrome, adequate urine output is crucial. For a child weighing 12 kg, an output of around 30 mL/hr (or 240 mL over 8 hours) is considered normal. 256 mL over 8 hr indicates adequate urine production
C. No pain with voiding is a positive sign but doesn't necessarily indicate overall effectiveness of treatment for nephrotic syndrome.
D. Odourless urine is a normal finding and not necessarily an indicator of treatment success.
Correct Answer is D
Explanation
A. Provide balloons for play. Balloons are a choking hazard for toddlers and should be avoided.
B. Adjust the water heater temperature to 54° C (129.2° F). The recommended safe water heater temperature is around 49° C (120° F) to prevent burns. 54° C (129.2° F) is too high and poses a burn risk.
C. Place screens on all windows. While screens can prevent insects from entering, they do not provide enough protection to prevent a child from falling out. Window guards or stops are more appropriate for preventing falls.
D. Check clothing for loose buttons. Loose buttons can be a choking hazard for toddlers, so it is important to check and secure them properly to prevent accidental ingestion.
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