A client is admitted with suspected pneumonia from the emergency department.
The client went to the primary healthcare provider a "few days ago" and shows the nurse the results of what the client calls "an allergy test," as shown below: The reddened area is firm. What action by the nurse is best?
Assess the client for possible items to which he or she is allergic.
Call the primary healthcare provider's office to request records.
Immediately place the client on Airborne Precautions.
Prepare to begin administration of intravenous antibiotics.
The Correct Answer is C
Choice A rationale
Assessing for general allergies is a good nursing practice but is not the most immediate priority when a client presents with a firm, reddened area after a "few days ago" allergy test, especially in the context of suspected pneumonia. This finding strongly suggests a specific type IV hypersensitivity reaction, common in tuberculosis screening.
Choice B rationale
Requesting records is important for comprehensive care, but delaying immediate action based on a highly suggestive clinical finding is not the best initial response. The appearance of the "allergy test" result is a critical piece of information that warrants immediate action to protect others.
Choice C rationale
A firm, reddened area on an "allergy test" a few days prior, especially with suspected pneumonia, is highly indicative of a positive tuberculin skin test (TST), signifying a past or present *Mycobacterium tuberculosis* infection. This necessitates immediate Airborne Precautions to prevent transmission of potential active tuberculosis, given the pulmonary symptoms.
Choice D rationale
Administering intravenous antibiotics for pneumonia is appropriate if bacterial pneumonia is confirmed. However, the presence of a positive TST-like reaction shifts the immediate priority to preventing airborne transmission of tuberculosis, requiring isolation measures *before* starting broad-spectrum antibiotics for pneumonia, which may not even be the primary issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Room temperature water is optimal for hydration in asthmatic children because it is less likely to trigger bronchospasm. Cold fluids can irritate the sensitive airways and cause constriction of the smooth muscles surrounding the bronchioles, exacerbating respiratory symptoms in individuals with reactive airways like asthmatics.
Choice B rationale
Carbonated beverages are generally not recommended for asthmatic children. The carbonation can cause bloating and discomfort, potentially leading to increased pressure on the diaphragm and exacerbating breathing difficulties. Additionally, the sugars and artificial ingredients in some carbonated drinks may not be ideal for overall health.
Choice C rationale
Iced fruit juice, similar to other cold beverages, can induce bronchospasm in susceptible individuals with asthma. The cold temperature can trigger airway hyperreactivity, leading to narrowing of the airways and worsening of asthmatic symptoms. Therefore, it is best to avoid very cold drinks.
Choice D rationale
Cold milk, like other cold beverages, can potentially trigger bronchoconstriction in asthmatic children due as it can irritate sensitive airways. Furthermore, some individuals with asthma may have co-existing milk allergies or sensitivities that can exacerbate respiratory symptoms, making it a less optimal choice.
Correct Answer is C
Explanation
Choice A rationale
A decrease in respiration rate from 40 to 32 breaths/min in an infant with RSV, while a reduction, does not necessarily indicate immediate deterioration requiring urgent reporting unless accompanied by other signs of respiratory distress. The normal respiratory rate for an infant typically ranges from 30 to 60 breaths/min. This change might reflect an improvement or a less acute phase.
Choice B rationale
A decrease in heart rate from 110 to 100 beats/min in an infant, while a slight reduction, still falls within the normal range for an infant's heart rate (typically 90-160 beats/min). This change alone is not usually indicative of immediate critical deterioration, especially without accompanying signs of hypoxemia or circulatory compromise.
Choice C rationale
A "quiet chest" following a previous assessment of wheezing in an infant with RSV is an ominous sign. Wheezing is caused by air moving through constricted airways. A sudden cessation of wheezing, despite persistent respiratory distress, suggests severe bronchoconstriction and impending respiratory failure, as airflow has become so minimal that it no longer produces audible sounds.
Choice D rationale
An oxygen saturation of 90% is below the acceptable normal range (typically 95-100%) and indicates hypoxemia, requiring attention and intervention. However, while concerning, it is not as immediately life-threatening as a "quiet chest" which signals impending respiratory arrest due to absent air movement.
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