A child is admitted to the pediatric unit with a diagnosis of Kawasaki disease. Which nursing intervention is most appropriate during this initial phase?
Administering antibiotics
Monitoring for signs of coronary artery aneurysms
Providing comfort measures for peeling skin on the hand
Administering intravenous immunoglobulin (IVIG)
The Correct Answer is D
A. Administering antibiotics is not appropriate as Kawasaki disease is not caused by a bacterial infection; it is an inflammatory condition.
B. While monitoring for signs of coronary artery aneurysms is essential, the immediate intervention needed in the initial phase is to administer IVIG to mitigate inflammation and prevent complications.
C. Providing comfort measures for peeling skin is supportive but does not address the critical treatment needs in Kawasaki disease.
D. Administering intravenous immunoglobulin (IVIG) is the priority nursing intervention as it helps reduce inflammation and the risk of developing cardiovascular complications associated with Kawasaki disease.
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Correct Answer is C
Explanation
A. Clients on digoxin should actually have an adequate intake of potassium, as low potassium levels can increase the risk of digoxin toxicity.
B. If a pediatric client spits out digoxin, the dose should not be repeated automatically; instead, the nurse should assess the situation and follow the facility's protocol regarding missed doses.
C. Measuring the apical pulse for one full minute before administering digoxin is critical; if the pulse is below the established threshold (usually <60 bpm for children), the medication should be held and the provider notified.
D. While evaluating for nausea, vomiting, and anorexia is important, it is not an appropriate immediate action before administering the medication. The priority action is to assess the apical pulse.
Correct Answer is C
Explanation
A. While child protective services may be necessary in cases of abuse or neglect, it is premature to take this action without understanding the family's dynamics and assessing the parent’s knowledge and skills regarding asthma management.
B. Providing a detailed medication schedule and healthcare provider information is helpful but does not actively engage the parent in the child's care or education about asthma management.
C. Empowering the parent through comprehensive education will foster engagement and collaboration, equipping them with the knowledge needed to support their child's asthma management effectively at home.
D. Reviewing the asthma action plan is important, but it should involve both the child and parent to ensure that the parent is actively engaged and understands how to implement the plan.