A client with dengue fever is experiencing severe plasma leakage and organ failure. The nurse observes the client has melena and hepatic damage. Which action is the nurse's priority?

Choice A rationale:

During the critical phase of dengue fever, which typically occurs around 3-7 days after the onset of symptoms, the client is at a higher risk of developing severe bleeding and organ failure due to plasma leakage and decreased platelet counts. Assessing for signs of bleeding, such as petechiae, ecchymosis, gum bleeding, or hematuria, is essential to detect any worsening condition promptly. Additionally, monitoring for signs of organ failure, such as altered mental status, respiratory distress, or oliguria, is crucial for timely intervention and appropriate management.

Choice B rationale:

Providing supplemental oxygen as needed may be beneficial in certain cases of dengue fever with respiratory distress or hypoxemia. However, during the critical phase, the priority is to assess for bleeding and organ failure, as these complications pose a more immediate threat to the client's life.

Choice C rationale:

Monitoring intake and output is a crucial nursing intervention for clients with dengue fever to ensure adequate hydration and prevent dehydration. While this is essential throughout the course of the illness, it is not the priority during the critical phase when bleeding and organ failure are of greater concern.

Choice D rationale:

Administering antipyretics for fever control may be necessary in the febrile phase of dengue fever to alleviate discomfort and manage fever. However, during the critical phase, the priority shifts to assessing for and managing potentially life-threatening complications like bleeding and organ failure.

Choice A rationale:

Elevating the client's legs may be helpful in certain situations to improve venous return and manage hypotension. However, during severe plasma leakage and organ failure in dengue fever, the priority is to control bleeding, and applying pressure to bleeding sites can help achieve hemostasis.

Choice B rationale:

Applying pressure to bleeding sites is a priority intervention in clients with dengue fever experiencing severe plasma leakage and melena. This helps to control bleeding and prevent further blood loss, which is vital during the critical phase.

Choice C rationale:

Administering acetaminophen for pain relief can be appropriate for clients with dengue fever, especially in the febrile phase when fever and discomfort are prominent. However, during the critical phase with plasma leakage and organ failure, the priority is to manage life-threatening complications like bleeding and hepatic damage.

Choice D rationale:

Providing supplemental oxygen is essential for clients experiencing respiratory distress or hypoxemia. However, in the scenario described, the client's main priority is controlling bleeding and managing organ failure rather than addressing respiratory issues.