A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse’s priority?
Obtain blood cultures.
Administer an intravenous antibiotic.
Prepare the child for a lumbar puncture.
Place the child in isolation.
The Correct Answer is B
Choice A rationale
Obtaining blood cultures is important for identifying the causative organism, but it should be done immediately before or concurrently with the administration of antibiotics.
Choice B rationale
Administering an intravenous antibiotic is the priority action for a child with suspected bacterial meningitis. Early administration of antibiotics is crucial to treat the infection and prevent complications such as brain swelling and seizures.
Choice C rationale
Preparing the child for a lumbar puncture is necessary for diagnosing meningitis, but it should not delay the administration of antibiotics.
Choice D rationale
Placing the child in isolation is important to prevent the spread of infection, but it is not the immediate priority over administering antibiotics.
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Correct Answer is A
Explanation
Choice A rationale
Shaking the inhaler for 3 to 5 seconds ensures that the medication is properly mixed and ready for administration. This step is crucial for delivering the correct dose of medication.
Choice B rationale
Pressing down twice on the MDI canister is incorrect as it can lead to an overdose of medication. The correct technique involves pressing down once per inhalation.
Choice C rationale
Waiting 2 minutes between inhalations is not necessary. The recommended wait time between inhalations is usually 30 seconds to 1 minute.
Choice D rationale
Rinsing the mouth with mouthwash after inhaling the medication is not recommended. Instead, rinsing with water is advised to prevent oral thrush, especially when using corticosteroid inhalers.
Correct Answer is D
Explanation
Choice A rationale
Asthma is a chronic respiratory condition characterized by airway inflammation and bronchoconstriction. It is not commonly associated with tetralogy of Fallot.
Choice B rationale
Polycythemia, or an increased number of red blood cells, can occur as a compensatory mechanism in response to chronic hypoxia in tetralogy of Fallot. However, it is not a primary condition associated with tetralogy of Fallot.
Choice C rationale
Pulmonary hypertension is a condition characterized by increased blood pressure in the pulmonary arteries. While it can occur secondary to congenital heart defects, it is not a primary condition associated with tetralogy of Fallot.
Choice D rationale
Tetralogy of Fallot is a congenital heart defect that includes four heart abnormalities: ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. These defects cause altered blood flow and reduced oxygen levels in the blood.