A client taking antibiotics for three days to treat a Streptococcal throat infection returns to the clinic reporting a feel itchy rash across the chest and arms. The nurse auscultates pulmonary wheezing and an elevated heart rate. Which action should the nurse implement?

Swab the throat for a rapid strep test.

Provide a mask for the client to wear.

Instruct client to stop taking the antibiotics.

Apply a hypoallergenic cream to the rash.

Answer and Explanation

The Correct Answer is C

Choice A reason: Swabbing the throat for a rapid strep test is not a priority action that the nurse should implement, because it is not relevant to the client's current condition. A rapid strep test is a diagnostic tool that can detect the presence of Streptococcus bacteria in the throat, which can cause strep throat, a common bacterial infection. However, the client has already been diagnosed with strep throat and has been taking antibiotics for three days, so the test result may not be accurate or useful.

Choice B reason: Providing a mask for the client to wear is not a necessary action that the nurse should implement, because it is not related to the client's problem. A mask is a protective device that can prevent the transmission of respiratory infections, such as COVID-19, influenza, or tuberculosis, by blocking the droplets or aerosols that contain the pathogens. However, the client's symptoms are not caused by a respiratory infection, but by an allergic reaction to the antibiotics, which is not contagious.

Choice C reason: Instructing the client to stop taking the antibiotics is the most important action that the nurse should implement, because it can prevent further exposure to the allergen and reduce the severity of the reaction. The client's symptoms, such as rash, wheezing, and tachycardia, indicate that the client is having an allergic reaction to the antibiotics, which can be a serious and potentially life-threatening condition, especially if it progresses to anaphylaxis, a severe systemic reaction that can cause shock, airway obstruction, and organ failure. The nurse should instruct the client to stop taking the antibiotics immediately and notify the doctor.

Choice D reason: Applying a hypoallergenic cream to the rash is not a sufficient action that the nurse should implement, because it can only provide temporary relief and not address the underlying cause of the rash. A hypoallergenic cream is a topical product that can moisturize, soothe, and protect the skin, and it does not contain any ingredients that can cause allergic reactions. However, the rash is not caused by a skin irritant, but by a systemic reaction to the antibiotics, which requires more than a cream to treat.

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Correct Answer is C

Explanation

Choice A reason: Calculating gestation from last menstrual cycle is not a reliable way to determine if the client is pregnant, and it is not an urgent intervention that the nurse should implement immediately. The last menstrual cycle may not reflect the actual date of conception, and it may vary depending on the client's cycle length, ovulation time, and other factors. The nurse should use a more accurate and objective method to confirm or rule out pregnancy, such as a urine or blood test.

Choice B reason: Continuing with surgery as scheduled is not a safe or ethical intervention that the nurse should implement immediately, without verifying the client's pregnancy status. Surgery, especially abdominal surgery, can pose significant risks to the client and the fetus, such as bleeding, infection, anesthesia complications, preterm labor, and miscarriage. The nurse should inform the surgical team about the possibility of pregnancy and obtain the client's informed consent before proceeding with surgery.

Choice C reason: Performing a bedside pregnancy test is the most appropriate and timely intervention that the nurse should implement immediately, given the client's situation. A bedside pregnancy test is a simple and quick way to detect the presence of human chorionic gonadotropin (hCG), a hormone produced by the placenta, in the client's urine. A positive result indicates that the client is pregnant, and a negative result indicates that the client is not pregnant. The nurse should perform the test as soon as possible and report the result to the surgical team and the client.

Choice D reason: Notifying the surgical team to cancel the surgery is not a necessary or prudent intervention that the nurse should implement immediately, without confirming the client's pregnancy status. Canceling the surgery may delay the treatment of the client's acute appendicitis, which can lead to serious complications, such as perforation, abscess, peritonitis, and sepsis. The nurse should first perform a bedside pregnancy test and then discuss the risks and benefits of surgery with the surgical team and the client.

A. Platelet count. B. Serum albumin. C. Neutrophil count. D. Blood pH level.

Correct Answer is C

Explanation

Choice A reason: Platelet count is not directly related to wound infection. Platelets are involved in blood clotting and hemostasis. A low platelet count can increase the risk of bleeding, while a high platelet count can indicate inflammation or malignancy.

Choice B reason: Serum albumin is a measure of protein status and nutritional status. A low serum albumin can indicate malnutrition, liver disease, kidney disease, or fluid imbalance. A high serum albumin can indicate dehydration or chronic infection. Serum albumin is not a specific indicator of wound infection.

Choice C reason: Neutrophil count is a measure of the body's immune response to infection. Neutrophils are the most abundant type of white blood cells and are the first line of defense against bacterial infections. A high neutrophil count can indicate an acute infection, while a low neutrophil count can indicate a weakened immune system or a chronic infection. Neutrophil count is the most relevant laboratory value to evaluate wound infection.

Choice D reason: Blood pH level is a measure of the body's acid-base balance. A normal blood pH level is between 7.35 and 7.45. A low blood pH level can indicate acidosis, while a high blood pH level can indicate alkalosis. Blood pH level can be affected by many factors, such as respiratory function, metabolic function, renal function, and medication use. Blood pH level is not a specific indicator of wound infection.

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A client taking antibiotics for three days to treat a Streptococcal throat infection returns to the clinic reporting a feel itchy rash across the chest and arms. The nurse auscultates pulmonary wheezing and an elevated heart rate. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

Correct Answer is C

Explanation

While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?

Correct Answer is C

Explanation

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