A client is admitted to the medical-surgical unit with a 3-week history of a productive cough, night sweats, low-grade fever, and unexplained weight loss. The client reports feeling fatigued and has decreased appetite. Based on these assessment findings, which intervention should the nurse implement first?
Placing the client in airborne isolation
Obtaining sputum cultures
Monitoring the client's fluid intake and output
Assessing the client's temperature every 8 hours
The Correct Answer is A
Rationale:
A. Placing the client in airborne isolation: The client’s symptoms strongly suggest pulmonary tuberculosis. Airborne isolation prevents transmission of Mycobacterium tuberculosis to healthcare workers and other clients, making infection control the first concern.
B. Obtaining sputum cultures: Sputum cultures are necessary to confirm TB diagnosis and guide treatment. However, cultures should be obtained only after the client has been placed in proper isolation to prevent potential spread of infection during the collection process.
C. Monitoring the client's fluid intake and output: While hydration status is important in clients with fever, weight loss, and decreased appetite, it is not an immediate priority compared to preventing transmission of a highly contagious airborne disease.
D. Assessing the client's temperature every 8 hours: Monitoring fever helps track infection severity but does not address the urgent risk of spreading TB. Infection control measures take precedence before routine monitoring can be performed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Highly self-directed people reflect low intolerance of change: This description does not explain the development of personality disorders. Self-direction is generally considered a positive trait that supports adaptability, not a factor leading to pathology.
B. Failure to complete developmental tasks: According to Erikson and other developmental theories, unresolved developmental stages such as trust, identity, or intimacy can lead to maladaptive coping patterns that evolve into personality disorders.
C. Cooperative people become less helpless over time: This reflects a positive growth pattern, not a factor in personality disorder development. Increased cooperation typically strengthens relationships and resilience rather than causing pathology.
D. Self-transcendence contributes to unaware self-consciousness: Self-transcendence is usually considered a positive quality associated with spirituality or meaning-making, not a cause of disordered personality development.
Correct Answer is ["22.8"]
Explanation
Calculation:
- Calculate the total dose in milligrams (mg) for the client's weight.
Total dose (mg) = Patient weight (kg) x Ordered dose (mg/kg)
= 95 kg x 6 mg/kg
= 570 mg.
Available concentration = 250 mg / 10 mL
= 25 mg/mL.
- Calculate the volume to administer in milliliters (mL).
Volume to administer (mL) = Total dose (mg) / Available concentration (mg/mL)
= 570 mg / 25 mg/mL
= 22.8 mL.
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