A 4-year-old child with rubeola (measles) is hospitalized with complications. Which nursing intervention is the highest priority for this child?
1Administer vitamin A supplementation as prescribed
2Provide frequent oral hygiene and mouth care
3Maintain strict bed rest until fever subsides
4Monitor respiratory status and maintain airway patency✓ 정답
해설
Monitoring respiratory status and maintaining airway patency is the highest priority for a child with measles complicated by pneumonia, as respiratory compromise can be life-threatening. Other interventions like vitamin A, oral care, and bed rest are important but secondary to airway management.
Core Nursing ExplanationKey Concept Analysis: This question tests the application of nursing priorities and the ABC (Airway, Breathing, Circulation) framework in a pediatric patient with a serious infectious disease complication. The core theme is recognizing that a child hospitalized with complications from Rubeola (Measles) is at high risk for severe respiratory issues, which are the leading cause of measles-related mortality. The pathophysiology involves the measles virus causing immunosuppression and damaging the respiratory epithelium, making the child highly susceptible to secondary bacterial infections like pneumonia, which is the most common fatal complication.
Answer Rationale: Key Point! Option ④ is correct because it directly addresses the primary survey (ABCs). In any patient, but especially in a pediatric patient with a respiratory-compromising infection, airway patency and effective breathing are the highest priorities. A compromised airway or respiratory failure is an immediate threat to life. Monitoring includes assessing for tachypnea (rapid breathing), retractions (use of accessory muscles), nasal flaring, grunting, cyanosis (bluish discoloration), and changes in level of consciousness.
Distractor Analysis:
Watch out for confusion! Option ① (Administer vitamin A): The World Health Organization (WHO) recommends vitamin A for children with measles in areas where deficiency is common, as it can reduce morbidity and mortality. However, this is a supportive pharmacological intervention, not the immediate life-saving priority when a child is hospitalized with complications.
Option ② (Provide oral hygiene): Children with measles often have Koplik's spots (small white spots on the buccal mucosa) and may develop stomatitis, making oral care important for comfort and nutrition. This is a comfort and hygiene measure, not a priority over airway management.
Option ③ (Maintain strict bed rest): While rest is important for recovery and energy conservation, "strict" bed rest is not typically the priority. Furthermore, activity may be encouraged as tolerated to prevent complications of immobility and to help with pulmonary hygiene. This is a general supportive measure.
Related Concepts: The NCLEX-RN frequently tests the ability to triage nursing actions using frameworks like ABCs, Maslow's Hierarchy of Needs (physiological needs first), and safety and risk reduction (addressing the greatest threat first). Always ask: "Which action, if not done first, could lead to the most immediate harm or death?"
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a pediatric unit. A 4-year-old named Leo is admitted with a diagnosis of measles complicated by pneumonia. He has a high fever, a barking cough, and the classic measles rash. His mother reports he is working hard to breathe and is very lethargic.
Nursing Intervention Strategy:
1Assessment (The First 5 Minutes)Immediately perform a focused respiratory assessment. Use the Pediatric Assessment Triangle (PAT): Appearance (lethargic?), Work of Breathing (retractions, nasal flaring, grunting?), Circulation to Skin (pale, mottled, cyanotic?). Count the respiratory rate for a full minute. Listen to lung sounds for crackles, wheezes, or diminished breath sounds. Check oxygen saturation via pulse oximetry.
2Priority ActionIf respiratory distress is identified, initiate oxygen therapy as ordered via the appropriate device (e.g., nasal cannula, simple face mask). Position the child to maximize airway opening (e.g., semi-Fowler's or Fowler's position). Have suction equipment ready at the bedside.
3Ongoing Monitoring & Collaborative CareDocument vital signs and respiratory assessment findings frequently (e.g., every 1-2 hours initially). Administer prescribed antibiotics for secondary bacterial pneumonia and antipyretics for fever. Ensure isolation precautions are in place (Airborne Precautions for measles).
4Supportive Care & EducationOnce the airway and breathing are stable, implement the other important interventions: Provide gentle oral care. Administer vitamin A if prescribed. Encourage fluid intake to prevent dehydration. Educate the family on the importance of vaccination to prevent measles.
Patient Safety and Precautions:
1Infection ControlMeasles is one of the most contagious diseases. The child must be placed in a negative pressure airborne infection isolation room (AIIR). Anyone entering must wear an N95 respirator or higher. Standard and Contact Precautions are also used.
2MedicationVitamin A supplementation is given orally. Be aware of the dosing schedule (often given on two consecutive days).
Nursing Procedure & Medication FlowAirway & Respiratory Monitoring Procedure:
1. Assess: Rate, rhythm, depth, effort (look for retractions), sounds (stridor, wheeze), color (lips, nail beds).
2. Measure: Obtain accurate Oxygen saturation (SpO2) - Normal: ≥95%. A value of <90% is a critical finding requiring immediate intervention.
3. Intervene: Administer oxygen. Position. Prepare for possible advanced airway management (e.g., intubation) if severe distress develops.
4. Document: Trends are key. Note any deterioration or improvement.
A Word from Your Senior Nurse: "In pediatrics, kids can decompensate quickly. That barky cough and increased work of breathing in a measles patient are huge red flags. Your eyes and ears are your best assessment tools—don't just rely on the monitor. Seeing subcostal retractions or hearing stridor means you act NOW, not after you've given the vitamin A. Always think ABCs first. This mindset of rapid primary assessment is what saves lives and is exactly what the NCLEX wants you to demonstrate."
Rubeola — A highly contagious viral illness characterized by fever, cough, coryza (runny nose), conjunctivitis, and a maculopapular rash. It causes significant immunosuppression.
Koplik's Spots — Small, white spots with a bluish-white center on a red background found on the buccal mucosa; a pathognomonic sign of measles appearing 1-2 days before the rash.
Airborne Precautions — Infection control measures for diseases transmitted by airborne droplet nuclei (e.g., measles, tuberculosis, chickenpox). Requires a negative pressure room and an N95 respirator.
Pediatric Assessment Triangle — A rapid, 15-30 second initial assessment tool evaluating Appearance, Work of Breathing, and Circulation to skin to identify sick versus not-sick children.
Tachypnea — An abnormally rapid respiratory rate. In a 4-year-old, a rate consistently above 30-40 breaths per minute (depending on source and fever) may indicate respiratory distress.