A charge nurse is observing a staff nurse who is caring for a child who has pertussis.
Which of the following actions by the staff nurse indicates an understanding of infection control practices?
Maintains droplet precautions while the child is coughing and sneezing
Applies a face mask after entering the child's room
Wears gloves when assisting the child to the bathroom
Follows airborne precautions by wearing an N95 respirator while caring for the child
The Correct Answer is A
Rationale:
A. Maintaining droplet precautions while the child is coughing and sneezing is appropriate because pertussis is primarily transmitted via respiratory droplets. Droplet precautions include wearing a surgical mask when within 3 feet of the patient to prevent droplet transmission.
B. Applying a face mask after entering the child's room is not necessary if droplet precautions are already being followed during periods of coughing and sneezing.
C. Wearing gloves when assisting the child to the bathroom is not directly related to preventing the spread of pertussis, which is primarily transmitted via respiratory droplets.
D. Airborne precautions with an N95 respirator are not indicated for pertussis, as it is not transmitted via airborne particles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Tachypnea (rapid breathing) is a common clinical manifestation of heart failure due to decreased cardiac output and inadequate tissue perfusion.
B. Tremors are not typically associated with heart failure.
C. Increased appetite is not typically associated with heart failure and may even be decreased due to symptoms such as fatigue and dyspnea.
D. Bradycardia (slow heart rate) is not typically associated with heart failure; instead, tachycardia (rapid heart rate) may occur as a compensatory mechanism.
Correct Answer is []
Explanation
Correct Answers:
Condition Most Likely Experiencing: C
Actions to Take: A, B
Parameters to Monitor: B, C
Rationale:
Condition Most Likely Experiencing
A. Pyloric stenosis causes projectile vomiting, dehydration, and hunger.
B. Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.
C. The condition that the infant is most likely experiencing is congestive heart failure, which can cause poor weight gain, tachypnea, decreased appetite, and periorbital edema.
D. Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.
Actions to Take
A. Elevating the head of the bed can help reduce the workload of the heart and improve breathing.
B. Digoxin can increase the contractility of the heart and decrease the heart rate.
C. Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
D. Chest physiotherapy and postural drainage are not indicated for congestive heart failure, but for conditions that cause excessive mucus production and retention.
Parameters to Monitor
A. Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
B. Intake and output can indicate fluid balance and renal function.
C. Respiratory status can reflect cardiac function and oxygenation.
D. Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.
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