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 B
Explanation
Choice A rationale
Droplet precautions are used for infections spread through large respiratory droplets, such as influenza, but are not sufficient for measles.
Choice B rationale
Airborne precautions are necessary for measles, as it is spread through small droplets that can remain suspended in the air and travel over long distances.
Choice C rationale
Contact precautions are used for infections spread through direct contact with the patient or their environment, such as MRSA, but are not sufficient for measles.
Choice D rationale
A protective environment is used for patients with compromised immune systems to protect them from infections, not for preventing the spread of infections like measles.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Restraining the client during a seizure is not recommended as it can cause injury. The focus should be on ensuring the client’s safety and preventing harm.
Choice B rationale
Assessing the client’s airway patency is crucial during a seizure to ensure that the client is breathing properly and that the airway is not obstructed.
Choice C rationale
Removing objects from the client’s bed helps prevent injury during a seizure. Objects in the bed can pose a risk of harm if the client hits them during the seizure.
Choice D rationale
Placing the client in a side-lying position helps maintain an open airway and reduces the risk of aspiration. This position allows any secretions to drain out of the mouth, preventing choking.
Choice E rationale
Placing a tongue depressor in the client’s mouth is not recommended and can cause injury. It is a common misconception that this prevents the client from swallowing their tongue, but it can actually cause more harm.