A 7-year-old child is admitted to the pediatric unit with suspected diphtheria. Which nursing action is the highest priority to ensure safety for other patients and healthcare workers?
1Administer diphtheria antitoxin as prescribed
2Monitor for signs of airway obstruction
3Implement strict droplet and contact isolation precautions immediately✓ 정답
4Obtain throat culture for laboratory confirmation
해설
Immediate implementation of strict droplet and contact isolation precautions is the highest priority to prevent transmission of this highly contagious disease. Other actions like antitoxin administration are important but secondary for infection control.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing action for a patient with a suspected highly contagious infectious disease. The core principle is Infection Control and Prevention. For any patient with a suspected or confirmed communicable disease, the nurse's first action is to implement appropriate isolation precautions to protect other patients, visitors, and healthcare workers. This aligns with the nursing process where safety (preventing transmission) is assessed and addressed before specific disease management.
Answer Rationale: Key Point!Diphtheria is caused by Corynebacterium diphtheriae and is transmitted through respiratory droplets and direct contact with respiratory secretions or skin lesions. It is highly contagious. Therefore, the immediate priority is to break the chain of infection by placing the child in appropriate isolation. The Centers for Disease Control and Prevention (CDC) guidelines recommend both droplet precautions (for respiratory transmission) and contact precautions (for contact with secretions/lesions) for diphtheria. This action takes precedence because it protects public health.
Distractor Analysis:
Watch out for confusion! Option ①, administering diphtheria antitoxin, is a critical treatment to neutralize the toxin but is not the first safety priority for others. The antitoxin treats the patient, while isolation protects the community.
Option ②, monitoring for airway obstruction, is a high clinical priority for the individual patient's safety due to the risk of a pseudomembrane forming in the throat. However, the question specifically asks for the priority to ensure safety for other patients and healthcare workers, shifting the focus to infection control.
Option ④, obtaining a throat culture, is important for diagnostic confirmation. However, you do not wait for lab results to initiate standard precautions for a suspected highly contagious disease. "Suspected" in the question stem triggers the immediate action of isolation.
Related Concepts: This question integrates principles of public health nursing, standard and transmission-based precautions, and pediatric infectious disease management. Always remember the ABCs (Airway, Breathing, Circulation) for individual patient priority, but when the question specifies protecting others, infection control becomes the overriding "safety" priority.
Concept Summary
Concept
Key Points
Diphtheria Transmission
Respiratory droplets, direct contact with secretions. Highly contagious.
Negative pressure room, N95 respirator or PAPR for staff, patient wears mask during transport.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: C. diphtheriae produces a potent exotoxin that causes local tissue necrosis, leading to the formation of a tough, gray pseudomembrane in the pharynx/nose/tonsils. This membrane can obstruct the airway. The toxin can also be absorbed into the bloodstream, causing systemic effects like myocarditis and neuritis.
Pharmacology: Diphtheria antitoxin is a horse serum-derived antibody that neutralizes the unbound toxin. A skin test for horse serum sensitivity must be done prior to administration due to risk of anaphylaxis. Antibiotics (e.g., penicillin, erythromycin) are also given to kill the bacteria but do not neutralize existing toxin.
Memory Tips
Acronym: For diseases requiring Droplet + Contact precautions, think "Diphtheria is Double trouble" (needs two types).
Visual: Imagine the pseudomembrane as a "gray blanket" in the throat that can suffocate the patient (airway priority) and is full of germs that "jump" (droplet) and "stick" (contact) to others.
High-Frequency NCLEX Topics
NCLEX frequently tests transmission-based precautions. You must know which diseases require which type of isolation. Questions often present a "suspected" diagnosis and ask for the first or priority action. Remember: Safety first often means contain the infection first in these scenarios.
Watch Out for Question Variations!
Symptom Focus: "The nurse observes a gray membrane in a child's throat. Which action should the nurse take first?" (Answer: Place on droplet/contact isolation).
Intervention Focus: "Which personal protective equipment (PPE) is required when entering the room of a child with diphtheria?" (Answer: Gown, gloves, and mask).
Patient Priority Shift: "A child with diphtheria develops severe stridor. What is the nurse's priority?" (Answer shifts to individual patient: Airway management - prepare for intubation/suction).
Nursing Clinical Practice GuideClinical Scenario: You are the charge nurse in a busy pediatric emergency department. A frantic mother brings in her 7-year-old son, complaining of sore throat, fever, and "barking" cough for two days. On visual inspection, you note mild stridor and what appears to be a grayish coating on the back of his throat. The mother mentions other children at his school have been sick.
Nursing Intervention Strategy:
Immediate Action (Priority): From the moment "diphtheria" is suspected, escort the child and parent to a private isolation room immediately. Don appropriate PPE (gown, gloves, surgical mask) before further close assessment. Place a sign on the door indicating "Droplet & Contact Precautions." This is done before the full assessment or doctor's orders.
Assessment: Once isolated, perform a focused assessment: Monitor respiratory rate, effort, and for signs of airway obstruction (stridor, retractions, anxiety, cyanosis). Assess vital signs and the characteristics of the membrane.
Collaboration & Orders: Notify the physician and infection control department. Anticipate orders for throat culture, diphtheria antitoxin (after sensitivity testing), and antibiotics.
Patient/Family Education: Explain the reason for isolation in simple terms. Educate the family on strict hand hygiene. Discuss the importance of vaccination (DTaP/Tdap) for contacts.
Patient Safety and Precautions:
Airway: Have emergency airway equipment (suction, intubation tray, tracheostomy tray) readily available at the bedside. The pseudomembrane can suddenly occlude the airway.
Medication: The diphtheria antitoxin is a high-alert medication. Ensure a skin test for horse serum allergy is performed and documented before administration. Be prepared to manage anaphylaxis.
Reporting: Diphtheria is a reportable disease to public health authorities. The nurse often assists in this mandatory reporting process.
Place patient in a private room. If not available, cohort with another confirmed diphtheria case.
PPE Donning: Perform hand hygiene → Gown → Mask → Gloves.
PPE Doffing: Remove gloves → perform hand hygiene → remove gown → perform hand hygiene → remove mask → perform hand hygiene. This sequence prevents self-contamination.
Limit patient transport. If necessary, patient wears a surgical mask.
Use dedicated patient-care equipment (e.g., stethoscope, BP cuff). If sharing is unavoidable, clean and disinfect thoroughly.
A Word from Your Senior Nurse
"In the real world, your spider-sense should tingle the moment you hear 'suspected' with a disease like diphtheria or measles. Your first move isn't to run for the culture swab—it's to close the door and grab the PPE. Think of yourself as the guardian at the gate, stopping an outbreak before it starts. On the NCLEX, they are testing this instinct for safety—not just for your patient, but for the entire unit. Cultivate that mindset: 'What is the immediate threat, and to whom?' It will make you a safe nurse and help you crush these priority questions."
Droplet Precautions — Infection control measures used for diseases spread by large respiratory droplets (e.g., from coughing, sneezing) within about 3-6 feet. Requires a private room or cohorting and a surgical mask for close contact.
Contact Precautions — Infection control measures used for diseases spread by direct contact with the patient or indirect contact with contaminated surfaces/equipment. Requires a private room, and use of gown and gloves.
Pseudomembrane — A characteristic grayish, adherent membrane composed of fibrin, bacteria, and inflammatory cells that forms on mucous membranes (e.g., pharynx) in diphtheria. It can cause airway obstruction.
Diphtheria Antitoxin — A medication derived from horse serum that neutralizes the circulating exotoxin produced by Corynebacterium diphtheriae. A skin test for sensitivity must precede administration due to risk of anaphylaxis.
Chain of Infection — The sequence of events that allows an infection to spread: Infectious Agent → Reservoir → Portal of Exit → Mode of Transmission → Portal of Entry → Susceptible Host. Nursing interventions aim to break this chain.