A nurse in a clinic is caring for a patient whose partner states the patient woke up this morning, did not recognize him, and did not know where she was.

The patient reports chills and chest pain that is worse upon inspiration.

Which of the following actions is the nursing priority?

Choice A rationale

A patient with diarrhea may have a communicable disease, such as C. difficile or Norovirus. The patient with Stevens-Johnson syndrome has compromised skin integrity, making them highly susceptible to opportunistic infections. Placing them with a patient who has a potential infection poses a significant risk of cross-contamination and sepsis, which is a life-threatening complication for this vulnerable patient.

Choice B rationale

A patient with methicillin-resistant Staphylococcus aureus (MRSA) has a colonization or infection with a resistant bacteria. Stevens-Johnson syndrome involves extensive epidermal detachment, creating large areas of open, denuded skin, similar to a burn injury. This makes the patient extremely vulnerable to infection from resistant organisms like MRSA, which could lead to severe systemic infection and sepsis.

Choice C rationale

A patient with atrial fibrillation is not contagious and does not pose an infectious risk. Atrial fibrillation is a cardiac arrhythmia caused by an electrical conduction abnormality in the heart, with no risk of transmission. This roommate choice is the safest because it minimizes the risk of infection for the patient with Stevens-Johnson syndrome, whose compromised skin barrier makes them highly susceptible.

Choice D rationale

A fever of unknown origin (FUO) suggests an underlying infectious process that has not yet been identified. This poses a high risk of cross-contamination to the patient with Stevens-Johnson syndrome. The patient with compromised skin integrity is at an extreme risk of contracting a new infection from an undiagnosed and potentially contagious pathogen, which could lead to a severe and rapid decline in their condition.

Choice A rationale

While obtaining a complete history is important for diagnosis, it is not the immediate priority. The patient's altered mental status, chest pain, and chills suggest a serious infectious or cardiopulmonary process like pneumonia, which can rapidly progress. Delaying the assessment of vital signs and oxygen saturation to gather a detailed history could be detrimental, as the patient's condition may worsen during that time.

Choice B rationale

Providing a pneumococcal vaccine is a prophylactic measure for pneumonia prevention. While potentially relevant for a patient at risk for or diagnosed with pneumonia, it is not an immediate life-saving intervention. The priority is to assess and stabilize the patient's current condition, not to prevent a future illness. Vaccination is a secondary intervention once the patient is stabilized.

Choice C rationale

The nursing priority in this situation is to obtain baseline vital signs and oxygen saturation. The patient's symptoms of altered mental status, chest pain, and chills are red flags for a serious cardiopulmonary condition like pneumonia. Assessing vital signs, including oxygen saturation, provides crucial data to determine the severity of the illness and guide immediate interventions to stabilize the patient's condition. Normal oxygen saturation is 95-100%.

Choice D rationale

Obtaining a sputum culture is a diagnostic procedure used to identify the causative organism of a respiratory infection. While an important step for guiding targeted antibiotic therapy, it is not the nursing priority. Sputum collection can be time-consuming, and the results are not immediately available. The priority is to assess the patient's current physiological status and provide supportive care, such as oxygen, if needed, based on the vital signs