The nurse is caring for an infant who has impetigo and is hospitalized. Which nursing intervention is the highest priority for this child?
The nurse applies elbow restraints to the infant.
The nurse soaks the skin with warm water.
The nurse follows contact precautions.
The nurse applies topical antibiotics to the lesions.
The Correct Answer is C
A. The nurse applies elbow restraints to the infant:
The use of elbow restraints is not a standard intervention for impetigo. Restraints are typically used for specific medical reasons, such as preventing the infant from interfering with medical equipment or procedures. It is not the highest priority in managing impetigo.
B. The nurse soaks the skin with warm water:
Soaking the skin with warm water can help in keeping the affected areas clean and promoting healing, but it is not the highest priority when considering the prevention of the spread of impetigo.
C. The nurse follows contact precautions:
Following contact precautions is the highest priority when dealing with impetigo. Since impetigo is highly contagious, implementing contact precautions, such as wearing appropriate PPE, is crucial to prevent the spread of the infection within the hospital setting.
D. The nurse applies topical antibiotics to the lesions:
Applying topical antibiotics is an important part of the treatment for impetigo. It helps to eliminate the bacterial infection and promote healing. However, while important, it is not the highest priority compared to preventing the spread of the infection through contact precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Measles, Mumps, and Rubella (MMR):
The first dose of the MMR vaccine is usually administered around 12-15 months of age. Therefore, this vaccine is appropriate for a 15-month-old child's routine health visit.
B. Pneumococcal:
The pneumococcal vaccine is typically given in several doses, with one of the doses recommended around 12-15 months. It's part of the routine immunization schedule for this age range.
C. Meningococcal:
Meningococcal vaccines are not usually part of the routine schedule at 15 months of age unless there are specific risk factors or circumstances that necessitate this vaccination.
D. Rotavirus (RV):
The rotavirus vaccine is administered in multiple doses, usually starting at around 2 months and completing before 8 months of age. By 15 months, the child should have completed the recommended doses.
Correct Answer is B
Explanation
A. Sore throat:
A sore throat is a common symptom of various respiratory tract infections, including acute epiglottitis. However, examining the throat with a tongue depressor is unlikely to directly precipitate a sore throat in this context.
B. Complete obstruction:
Examining the child's throat with a tongue depressor in acute epiglottitis can potentially trigger spasm or swelling of the already inflamed epiglottis, leading to a rapid and complete obstruction of the airway. This is a critical concern and is why healthcare providers approach suspected cases of epiglottitis with great caution.
C. Inspiratory stridor:
Inspiratory stridor (high-pitched sound during inhalation) is a common symptom of upper airway obstruction, including in conditions like acute epiglottitis. It may be present without manipulation, but using a tongue depressor in the throat could exacerbate this symptom.
D. Respiratory tract infection:
Acute epiglottitis is indeed a type of respiratory tract infection. However, examining the throat with a tongue depressor is not likely to directly precipitate a respiratory tract infection.
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