The nurse is caring for a child who has cellulitis on the foot. Which is an appropriate nursing action? (Select all that apply)

Administer prescribed antibiotics

Monitor for spreading redness

Implement droplet precautions

Apply a topical antiviral cream.

Wash area with a pediculicide

Answer and Explanation

Correct Answer : A,B

A. Cellulitis is a bacterial infection of the skin and subcutaneous tissue, most commonly caused by streptococci or staphylococci. The primary treatment is systemic antibiotics as prescribed by the provider. Administering antibiotics helps eliminate the infection, prevent complications such as abscess or sepsis, and promote healing.
B. Monitoring the site closely for spreading redness, swelling, or streaking up the limb is essential because worsening erythema may indicate progression of the infection, need for stronger antibiotics, or possible complications such as lymphangitis. Careful documentation and timely reporting to the provider are critical nursing responsibilities.
C. Droplet precautions are used for respiratory infections spread through droplets, such as influenza. Cellulitis is not transmitted this way; standard precautions are sufficient.
D. Topical antiviral creams are used for viral infections such as herpes simplex or varicella-zoster, not bacterial infections like cellulitis.
E. Pediculicides are used for lice infestations, not bacterial skin infections. Washing with these products would be ineffective and inappropriate for cellulitis.

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Correct Answer is A

Explanation

A. A weight gain of 3 pounds in 24 hours indicates fluid retention, which can quickly progress to fluid overload, pulmonary edema, and heart failure. This is the priority finding to report.
B. Decreased muscle strength may occur due to electrolyte imbalance or fatigue but is not immediately life-threatening.
C. An elevated BUN is expected in chronic kidney disease and is not as urgent as acute fluid retention.
D. Bilateral 2+ pedal pulses are normal and do not require reporting.

A. Monospot test B. MRI of the ear C. Lumbar puncture D. Audiology consult

Correct Answer is D

Explanation

A. A Monospot test is used to detect infectious mononucleosis, which is unrelated to chronic ear infections.

B. MRI is generally reserved for evaluating structural abnormalities, tumors, or complications, not routine chronic otitis media.

C. Lumbar puncture is used to diagnose central nervous system infections or conditions like meningitis, not ear infections.

D. Chronic otitis media can lead to hearing loss or speech delays. An audiology consult is appropriate to assess the child’s hearing and determine if further intervention, such as hearing aids or surgical options, is needed.

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The nurse is caring for a child who has cellulitis on the foot. Which is an appropriate nursing action? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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