A 4-year-old child is admitted to the pediatric unit with suspected diphtheria. Which nursing action should be the HIGHEST priority to ensure safety for other patients and healthcare workers?
A 6-year-old child presents with a sore throat, low-grade fever, and difficulty swallowing. The child has a grayish-white membrane covering the tonsils and throat. The parents report that the child has not received routine immunizations. Laboratory results are pending, but diphtheria is suspected based on clinical presentation.
1Administer diphtheria antitoxin as prescribed
2Implement strict droplet and contact isolation precautions immediately✓ 정답
3Obtain throat culture and sensitivity testing
4Monitor respiratory status and prepare for potential tracheostomy
해설
Immediate strict droplet and contact isolation is the highest priority to prevent transmission of this highly contagious infection. Other actions are important but secondary to infection control.
Diphtheria is a highly contagious and potentially life-threatening infection caused by toxigenic strains of Corynebacterium diphtheriae and, as highlighted in the provided evidence, emerging pathogens like Corynebacterium ulcerans. The clinical presentation of a grayish-white pseudomembrane, sore throat, and difficulty swallowing in an unimmunized child is a classic and urgent red flag. When a patient with a suspected airborne or droplet-transmissible disease enters a healthcare setting, the foundational principle of safety—protecting other vulnerable patients and the healthcare team—must be addressed before any individual diagnostic or therapeutic intervention. The NCLEX-RN frequently tests this "safety first" hierarchy, where implementing transmission-based precautions is the immediate, independent nursing action that prevents an outbreak.
Analysis of the Correct Answer (Option 2)
Implementing strict droplet and contact isolation precautions immediately is the highest priority. Diphtheria is transmitted via respiratory droplets and direct contact with cutaneous lesions or contaminated fomites. By instituting these precautions at the point of suspicion, you create a physical barrier that breaks the chain of infection. This action is a nurse-driven, autonomous decision that does not require a provider's order to initiate and must be in place before the patient interacts with the broader hospital environment. The provided case report on C. ulcerans reinforces this urgency, describing it as an "emerging pathogen that can cause life-threatening disease" and emphasizing that clinicians must be vigilant "even in regions where diphtheria is rare" [1]. This underscores that the initial safety response to a diphtheria-like illness must be uniform and immediate, regardless of the specific Corynebacterium species.
Analysis of Incorrect Answers
Option 1: Administer diphtheria antitoxin as prescribed.
While diphtheria antitoxin is the definitive treatment to neutralize the circulating exotoxin, it is a dependent nursing action requiring a provider's prescription and often special procurement from public health authorities. Administering it is a critical but secondary step. The antitoxin does not prevent the patient from transmitting the pathogen to others during the time required to obtain and administer the medication. The safety of the many takes precedence over the immediate treatment of the one, making isolation the first physical intervention.
Option 3: Obtain throat culture and sensitivity testing.
Obtaining a throat culture is essential for confirming the diagnosis and guiding public health response, but it is a diagnostic step, not a safety intervention. The process of swabbing the oropharynx can induce coughing and aerosol generation, increasing the risk of transmission to the nurse if proper precautions are not already in place. The culture must be obtained after the nurse has donned appropriate personal protective equipment (PPE) as part of the isolation protocol.
Option 4: Monitor respiratory status and prepare for potential tracheostomy.
Monitoring for airway compromise from the expanding pseudomembrane is a critical ongoing assessment. However, preparing for a tracheostomy is a late-stage intervention for a life-threatening complication. This action addresses a potential consequence for the single patient, whereas isolation immediately addresses the active, ongoing risk to all other patients and staff on the unit. The principle of "airway, breathing, circulation" applies to the individual, but the principle of "safety and infection control" applies to the entire care environment and is the overriding priority in this scenario.
References (research sources)
[1]
Severe Respiratory Diphtheria-Like Illness Caused by Toxigenic Corynebacterium ulcerans.Research articleHelleren R, Fløystad HK, Tellefsen OA, Boskovic M, Skraastad T, Mengshoel AT, Alfsnes K, Skogen V. (2026) · DOI: 10.3201/eid3202.250908
Suspected Diphtheria: Immediate Nursing ActionPrioritizing Isolation to Break the Chain of Infection
For a child with a grayish-white pseudomembrane and no immunizations, suspect diphtheria and act immediately. The highest priority is to implement strict droplet and contact isolation at the point of suspicion, before any other intervention. This is an independent nursing action that does not require a provider order.
Place the patient in a single room with the door closed. Healthcare workers must wear a surgical mask and gown with gloves for all patient contact. Dedicated patient-care equipment must remain in the room. These precautions must be maintained until 2 negative cultures are obtained from the nose and throat at least 24 hours apart after antibiotic therapy completion.
Caution
Do not delay isolation to obtain cultures or administer treatment. The pseudomembrane can dislodge and cause sudden airway obstruction; keep emergency airway equipment at the bedside, but only after the patient is isolated.
Diphtheria — A highly contagious bacterial infection caused by Corynebacterium diphtheriae, characterized by a pseudomembrane in the throat and potentially fatal complications.
Transmission-Based Precautions — Infection control practices used in addition to standard precautions for patients with known or suspected highly transmissible pathogens; includes contact, droplet, and airborne categories.
Pseudomembrane — A grayish-white, adherent membrane formed on mucous membranes, a classic clinical sign of diphtheria that can cause airway obstruction.
Diphtheria Antitoxin — A medication containing antibodies against the diphtheria toxin, used to neutralize the toxin before it binds to cells; most effective when given early.
Chain of Infection — A model illustrating the six links required for an infection to spread: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.