The pediatric nurse prepares a care plan for a patient admitted to the intensive care unit for meningitis. Which nursing interventions does the nurse include in the care plan for this patient? (Select all answers that apply.)
A.
Assess and treat pain as needed.
B.
Implement transmission-based precautions.
C.
Initiate and maintain IV access.
D.
Monitor vital signs every 4 hours.
E.
Monitor neurological status and symptoms.
ANS: A, B, C, E
The nurse should initiate transmission-based precautions to help prevent transmission of infection. The nurse should initiate and maintain intravenous access (specify fluids and rate) as ordered. The nurse should monitor vital signs every 1 to 4 hours (depending on severity of symptoms) and place the patient on a cardiac monitor as indicated. The nurse should monitor neurological status and symptoms closely, comparing with baseline values for the child. Patients with meningitis often have pain, especially headaches, and the nurse should be prepared to assess and treat.
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