A nurse is caring for an 8-year-old client who has been diagnosed with acute rheumatic fever. Which action is the nurse's priority for a client with this presentation?
Reviewing the client's complete blood count (CBC).
Using a pain-rating tool to determine the severity of the joint pain.
Assessing the client's erythematous rash.
Auscultating the rate and characteristics of the child's heart sounds.
The Correct Answer is D
A. While reviewing the CBC is important, it is not the priority.
B. Assessing joint pain is necessary for managing symptoms, but it is not the most critical initial action.
C. Evaluating the erythematous rash is part of the assessment, but it does not take precedence.
D. Auscultating the heart is the priority because acute rheumatic fever can lead to carditis, which can cause significant and potentially life-threatening heart complications. Early detection of abnormal heart sounds is crucial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Applying topical diphenhydramine may help with local itching but is not the priority in a child with a known allergy to insect stings.
B. A cool pack can reduce swelling but is not the priority action if an allergic reaction is suspected.
C. Positioning the child with legs elevated is appropriate if there are signs of shock but does not address the immediate risk of airway compromise.
D. Assessing the client's airway and breathing rate is the priority because a child with a known allergy to insect stings is at risk for anaphylaxis, which can cause airway obstruction and respiratory distress. Early recognition and intervention are critical.
Correct Answer is A
Explanation
A. Keeping a dedicated thermometer in the toddler's room is an appropriate infection control measure to prevent cross-contamination with other patients.
B. RSV is primarily transmitted through droplet and contact, not airborne, so contact and droplet precautions are more appropriate than airborne precautions.
C. Nebulized racemic epinephrine is not typically used for RSV; it is more commonly used for croup. Treatment for RSV may include supportive care such as hydration and oxygen therapy.
D. While monitoring pulse oximetry is important, assessing it every 3 hours might be insufficient. Continuous monitoring may be more appropriate depending on the severity of the illness.
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