# A 6-year-old child is admitted to the pediatric unit with a diagnosis of measles. Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541887 > language: ko > subject: Infectious Diseases ## 문제 A 6-year-old child is admitted to the pediatric unit with a diagnosis of measles. Which nursing intervention should be the priority? ## 보기 1. Administer acetaminophen for fever reduction 2. Implement strict isolation precautions **✔ 정답** 3. Encourage increased fluid intake 4. Apply cool compresses to the rash **정답: 2** ## 해설 Strict isolation is the priority for measles to prevent airborne spread. Aspirin is contraindicated in children due to Reye's syndrome risk; use acetaminophen instead. ## 심화 해설 Priority Intervention: Infection Control The correct answer is to implement strict isolation precautions. Measles is one of the most highly contagious infectious diseases, caused by the measles virus. The virus is transmitted via airborne droplets and can remain suspended in the air for up to 2 hours after an infected person leaves the area. The incubation period ranges from 7 to 21 days, and individuals are contagious from 4 days before to 4 days after the onset of the characteristic rash . Given this extreme transmissibility, the immediate and highest priority upon admission is to protect other patients, visitors, and healthcare staff by preventing the spread of the virus. This aligns with the fundamental NCLEX-RN principle of prioritizing safety and infection control, which often takes precedence over other physiological needs in a healthcare setting when a community health risk is present. Why Airborne Precautions Are Essential Strict isolation for measles specifically requires airborne precautions, not just standard or droplet precautions. This involves placing the child in a negative-pressure isolation room (airborne infection isolation room, AIIR) with the door kept closed. Anyone entering the room must wear an N95 respirator or a powered air-purifying respirator (PAPR), regardless of their immune status, because the virus particles are small enough to remain airborne and be inhaled. The resurgence of measles in recent years, with over 2200 cases reported in 2025 and 2073 cases in the first half of 2026, is directly linked to declining vaccination rates, increasing the pool of susceptible individuals . In a hospital setting, a single unrecognized case can lead to a major outbreak, making immediate isolation the most critical nursing action to ensure optimal outcomes for the patient and public health safety. Analysis of Other Options While the other interventions are components of supportive care for a child with measles, they do not address the most immediate safety risk and are therefore lower priorities upon admission. - **Option 1: Administer acetaminophen for fever reduction.** Fever management is important for comfort and preventing febrile seizures, but it is a comfort measure, not a safety priority. The immediate threat of viral transmission to others outweighs the need to treat a non-life-threatening fever. - **Option 3: Encourage increased fluid intake.** Maintaining hydration is a key supportive measure, especially if the child has a fever, but it is not the first action upon admission. This intervention would be implemented after the child is safely placed in appropriate isolation. - **Option 4: Apply cool compresses to the rash.** This is a comfort measure for pruritus. The maculopapular rash of measles is not the primary source of contagion; the respiratory secretions are. Addressing skin discomfort is a lower priority than preventing an airborne disease outbreak. Clinical Decision-Making Using the Nursing Process In an NCLEX-RN context, when a question asks for the "priority" intervention, it is testing your ability to apply Maslow's hierarchy of needs and the ABCs (Airway, Breathing, Circulation) within a safety framework. However, for a highly contagious disease, the safety of the environment takes immediate precedence. The nursing process begins with assessment, but the first implementation step upon recognizing a suspected or confirmed case of measles is to initiate isolation. The pathophysiology of measles involves initial viral replication in the respiratory epithelium, followed by viremia and the widespread maculopapular rash. The period of highest contagion is during the prodromal phase (fever, cough, coryza, conjunctivitis) before the rash even appears, which is why prompt recognition and isolation by acute care nurses are central to management . ## 임상 시나리오 Measles Airborne Isolation Protocol Immediate Actions on Admission - Place the child directly into a negative-pressure airborne infection isolation room (AIIR) with the door kept closed at all times. - Post clear signage indicating "Airborne Precautions" on the door, including instructions for N95 respirator use. - Notify the infection prevention team and local public health department as measles is a reportable disease. Personal Protective Equipment (PPE) - All healthcare personnel entering the room must wear a fit-tested N95 respirator or powered air-purifying respirator (PAPR), regardless of documented immunity status. - Immunocompromised staff or those without evidence of immunity should not enter the room if possible. - Perform hand hygiene before and after patient contact, and after removing PPE. Patient and Family Education - Explain the reason for isolation in developmentally appropriate terms: "We need to keep the germs from traveling to other kids." - Instruct family members to wear an N95 respirator if staying in the room and to limit movement outside the isolation room. - Educate that the child is contagious from 4 days before to 4 days after rash onset and must remain isolated during this period. Ongoing Monitoring and Care - Monitor for complications such as otitis media, pneumonia, or encephalitis while maintaining strict isolation. - Coordinate care to cluster nursing interventions and minimize entries into the room, reducing exposure risk. - Ensure all equipment used in the room is dedicated to the patient or thoroughly disinfected before use on others. ## 핵심 개념 - **Airborne Precautions** — Infection control measures for pathogens transmissible over long distances by small droplet nuclei, requiring a negative-pressure room and N95 respirator. - **Negative-Pressure Isolation Room** — A single-occupancy room with monitored airflow where air is exhausted outside or filtered before recirculation, used to contain airborne pathogens. - **N95 Respirator** — A tight-fitting mask that filters at least 95% of airborne particles, essential personal protective equipment for airborne precautions. ## 같은 주제 문제 - [A nurse is assessing a child for possible measles. 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