A nurse is caring for a client who has measles. Which of the following types of precautions should the nurse implement?

Choice A reason: Informing the provider is necessary, but it is not the first action. Before contacting the provider, the nurse must gather immediate data to assess the severity of the client’s condition. Without objective information, communication with the provider may be incomplete or delayed in urgency.

Choice B reason: Obtaining a pulse oximetry reading is the priority because the client is experiencing shortness of breath and chest pain, which may indicate impaired oxygenation. Pulse oximetry provides rapid, non-invasive data about oxygen saturation, guiding immediate interventions. This step ensures that the nurse can quickly determine if supplemental oxygen or emergency measures are required.

Choice C reason: Administering pain medication is important for comfort, but pain management is not the priority when the client shows signs of possible respiratory compromise. Addressing oxygenation and circulation must come before pain relief in acute trauma situations.

Choice D reason: Requesting a chest x-ray is appropriate for diagnostic purposes, but it is not the first action. Imaging takes time and requires physician orders. Immediate assessment of oxygenation is more urgent to stabilize the client before further diagnostics.

Choice A reason: Incisional drainage positive for glucose indicates cerebrospinal fluid leakage, which is a complication, not an expected finding. This requires immediate intervention.

Choice B reason: Irritability is expected in infants postoperatively and can indicate increased intracranial pressure or discomfort. It is a common finding after shunt placement and requires monitoring.

Choice C reason: Drowsiness may occur but is concerning if excessive, as it can indicate shunt malfunction or increased intracranial pressure. It is not considered a normal expected finding.

Choice D reason: Decreased head circumference is not expected immediately after shunt placement. Head growth should stabilize over time, but a sudden decrease would be abnormal.