A nurse is caring for a client.
Which of the following actions should the nurse take? (Select all that apply.)
Wear a mask when caring for the client.
Place the client in private room.
Encourage the client to increase fluid intake.
Place the client on contact precautions.
Prepare to administer an antibiotic to the client.
Correct Answer : A,B,C
A. Wear a mask when caring for the client: This is an important action to prevent the spread of influenza, which is transmitted via respiratory droplets. Wearing a mask helps protect both the healthcare provider and other patients from potential exposure to the virus, especially in the early stages of the disease when the client is most contagious.
B. Place the client in a private room: This action is recommended to minimize the risk of transmitting the influenza virus to other patients. Isolating the client in a private room can help control the spread of infection, making it a necessary measure in this situation.
C. Encourage the client to increase fluid intake: Adequate hydration is essential for clients with influenza to help alleviate fever and maintain overall health. Increasing fluid intake supports the immune system and helps prevent complications such as dehydration, so encouraging the client to drink more fluids is appropriate.
D. Place the client on contact precautions: While contact precautions are essential for preventing the spread of infections transmitted by direct contact, they are not specifically necessary for influenza, which is primarily airborne and droplet transmitted. Standard precautions, including droplet precautions, are sufficient for managing a client with influenza.
E. Prepare to administer an antibiotic to the client: This action is not appropriate because influenza is a viral infection, and antibiotics are ineffective against viruses. Treatment for influenza typically involves antiviral medications if indicated, supportive care, and symptom management rather than antibiotics. Therefore, this option should not be included in the actions the nurse takes.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Repositioning in bed: While repositioning the client is important for comfort and preventing complications such as pressure ulcers, it is not the top priority immediately after a pneumonectomy. Proper positioning can help improve respiratory function, but ensuring the stability and function of chest drainage systems takes precedence in the immediate postoperative period.
B. Use of the incentive spirometer: Encouraging the use of an incentive spirometer is crucial for promoting lung expansion and preventing atelectasis. However, it is essential first to ensure that the client’s chest tube is functioning properly and that there are no complications from the surgery. While this intervention is important, it follows the need to assess the chest tube.
C. Application of antiembolism stockings: While applying antiembolism stockings is a good practice to prevent venous thromboembolism, it is not the highest priority in the immediate postoperative period. Other assessments and interventions, such as monitoring respiratory status and chest tube function, are more critical in this early stage after surgery.
D. Chest tube and pleura-vac assessment: This is the priority nursing intervention in the immediate postoperative period. After a pneumonectomy, monitoring the chest tube's placement, drainage output, and function is vital for ensuring that the pleural space is adequately drained and that there are no complications such as pneumothorax or hemothorax. This assessment is crucial for maintaining respiratory function and overall stability in the postoperative client.
Correct Answer is ["B","C","D"]
Explanation
A. Hypotension: While hypotension can occur in clients with acute respiratory failure (ARF), it is not a primary manifestation of the condition. Hypotension may arise due to other factors, such as sepsis or significant fluid loss, but is not universally present in ARF. Therefore, it is less likely to be a key finding in this context.
B. Severe dyspnea: This is a hallmark manifestation of ARF. Clients typically experience significant difficulty in breathing due to inadequate oxygenation or ventilation, leading to an urgent need for medical intervention. Monitoring for severe dyspnea is critical as it directly indicates the severity of respiratory distress.
C. Headache: Headaches can be a manifestation of acute respiratory failure, particularly due to hypoxia or hypercapnia (elevated carbon dioxide levels) affecting cerebral circulation. This symptom may arise as the body struggles to compensate for decreased oxygen levels, making it important to monitor in clients with ARF.
D. Decreased level of consciousness: This is a significant concern in ARF and can indicate worsening hypoxia or hypercapnia. Alterations in consciousness may range from confusion to unresponsiveness and require immediate evaluation and intervention, making it a critical manifestation to monitor.
E. Nausea: Although some clients may experience nausea as a secondary symptom due to anxiety or as a response to hypoxia, it is not a primary or definitive manifestation of acute respiratory failure. Therefore, while it may occur in some cases, it is not one of the key findings to consistently monitor in clients with ARF.
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