A nurse is caring for a client.

Exhibits

Based on the information in the EHR, which of the following actions should the nurse take? Select all that apply.

Wear a mask when caring for the client.

Place the client on airborne precautions.

Place the client in private room.

Prepare to administer an antibiotic to the client.

Encourage the client to increase fluid intake.

Answer and Explanation

Correct Answer : A,C,E

A. Wear a mask when caring for the client. Influenza B is transmitted through droplet particles, so healthcare providers should wear a mask within 3 to 6 feet of the client to reduce the risk of transmission.
B. Place the client on airborne precautions. Airborne precautions are not necessary for influenza B. Droplet precautions are required, which involve wearing a mask and placing the client in a private room if possible. Airborne precautions are typically reserved for infections like tuberculosis, measles, and varicella.
C. Place the client in a private room. Clients with influenza should be placed in a private room or cohorted with another client with the same strain of the virus to prevent the spread of infection. This is a standard infection control measure for droplet precautions.
D. Prepare to administer an antibiotic to the client. Influenza B is a viral infection, and antibiotics are ineffective against viruses. Antiviral medications like oseltamivir (Tamiflu) may be prescribed instead, particularly if the client is within the first 48 hours of symptom onset.
E. Encourage the client to increase fluid intake. Fever, increased respiratory rate, and flulike symptoms can contribute to dehydration, so increasing oral fluid intake helps prevent dehydration, loosen respiratory secretions, and support overall recovery.

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Correct Answer is C

Explanation

A. Differences in upper and lower lung sounds. While pericarditis may cause pleuritic chest pain and a pericardial friction rub, differences in lung sounds between upper and lower fields are more commonly associated with pulmonary conditions like pneumonia or pleural effusion rather than atrial fibrillation.
B. Differences between oral and axillary temperatures. Temperature discrepancies are not related to atrial fibrillation. Though pericarditis may be accompanied by fever due to inflammation, AF is primarily an electrical disturbance and does not directly impact body temperature regulation.
C. Different apical and radial pulses. A pulse deficit, where the apical pulse is higher than the radial pulse, is a hallmark sign of atrial fibrillation. This occurs because the irregular, rapid atrial contractions lead to some ventricular beats that are too weak to produce a palpable radial pulse, indicating ineffective cardiac output.
D. Different blood pressures in the upper limbs. Significant differences in blood pressure between the arms are more indicative of vascular conditions such as aortic dissection or subclavian artery stenosis rather than atrial fibrillation, which primarily affects heart rhythm rather than arterial perfusion.

A. Chest xray B. Echocardiogram C. Computed tomography (CT) scan D. Electrocardiogram (ECG)

Correct Answer is B

Explanation

A. Chest xray. A chest xray may show an enlarged cardiac silhouette ("water bottle heart") due to the accumulation of pericardial fluid, but it is not the most immediate or definitive diagnostic tool for cardiac tamponade.
B. Echocardiogram. An echocardiogram is the firstline diagnostic test for suspected cardiac tamponade. It provides realtime imaging of the heart, allowing visualization of pericardial effusion, right ventricular collapse during diastole, and impaired cardiac filling, which are hallmark signs of tamponade. It is noninvasive, rapid, and highly sensitive, making it the preferred initial test.
C. Computed tomography (CT) scan. A CT scan can detect pericardial effusion, but it is not the first choice due to longer imaging time and lower practicality in an emergent setting. It is often used when echocardiography is inconclusive or when other mediastinal pathology is suspected.
D. Electrocardiogram (ECG). An ECG in tamponade may show low voltage QRS complexes, electrical alternans, or nonspecific ST changes, but these findings are not definitive. ECG cannot directly visualize pericardial fluid or hemodynamic compromise, making it less useful than echocardiography for confirming the diagnosis.

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A nurse is caring for a client. Exhibits Based on the information in the EHR, which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

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A nurse is caring for a client.

Exhibits

Based on the information in the EHR, which of the following actions should the nurse take? Select all that apply.