A nurse is reinforcing teaching with a client who has streptococcal pharyngitis. Which of the following actions is appropriate for the nurse to include in the plan of care?
Place the client in a negative airflow room.
Implement droplet precautions.
Place the client on a fluid restriction.
Obtain a throat culture after the initial dose of antibiotics.
The Correct Answer is B
Choice A reason: This is not an appropriate action for this client because placing them in a negative airflow room is indicated for clients who have airborne infections, such as tuberculosis or measles, that can spread through small particles that remain suspended in air. Streptococcal pharyngitis, also known as strep throat, is caused by bacteria that spread through large respiratory droplets that fall within 3 feet from source.
Choice B reason: This is an appropriate action for this client because implementing droplet precautions can prevent transmission of streptococcal pharyngitis to others by contact with respiratory secretions or contaminated objects. The nurse should wear a surgical mask when entering the client's room and instruct visitors to do so as well. The nurse should also place a mask on the client when transporting them outside their room.
Choice C reason: This is not an appropriate action for this client because placing them on a fluid restriction can cause dehydration and impair mucosal healing. The nurse should encourage the client to drink plenty of fluids, such as water, tea, or broth, to soothe the throat and prevent dryness.
Choice D reason: This is not an appropriate action for this client because obtaining a throat culture after the initial dose of antibiotics can affect the accuracy of the test results and delay diagnosis and treatment. The nurse should obtain a throat culture before starting antibiotics to confirm the presence of streptococcal bacteria and guide antibiotic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Administering enemas 2 days before the procedure is not necessary for colonoscopy preparation. Enemas are usually given on the day of or the night before the procedure to empty the bowel and improve visibility.
Choice B reason: This is not necessary for a colonoscopy. A clear liquid diet for a shorter period, usually 12-24 hours, is sufficient.
Choice C reason: Expecting the provider to schedule another procedure to remove any polyps is not a valid instruction for colonoscopy preparation. Polyps are abnormal growths in the lining of the colon that can be benign or malignant. The provider can usually remove any polyps during the colonoscopy using a snare or a biopsy forceps.
Choice D reason: This is a standard bowel preparation instruction for colonoscopy to ensure a clear view of the colon during the procedure.
Correct Answer is A
Explanation
Choice A reason: This is an indication of a wound infection because redness around the incision line or erythema is a sign of inflammation that can result from bacterial invasion and proliferation in the wound site. The nurse should inspect the wound site for other signs of infection, such as warmth, swelling, pain, or purulent drainage, and collect wound cultures and administer antibiotics as prescribed.
Choice B reason: This is not an indication of a wound infection because serous wound drainage or clear, watery fluid is a normal finding in the first 3 days after surgery and indicates the initial phase of wound healing. The nurse should measure and document the amount and color of wound drainage and change the dressings as prescribed.
Choice C reason: This is not an indication of a wound infection because crusting along the incision or scab formation is a normal finding in the first 3 days after surgery and indicates the initial phase of wound healing. The nurse should avoid removing or picking at the crusts and keep the wound site clean and dry.
Choice D reason: This is not an indication of a wound infection because bruising around the wound or ecchymosis is a normal finding in the first 3 days after surgery and indicates tissue damage or bleeding from the surgical trauma. The nurse should monitor the size and color of the bruise and apply ice packs as prescribed.
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