During the prodromal stage of an infection, which is the priority nursing intervention?

Develop a plan for gradually increasing activity and mobility.

Begin discharge planning and teaching.

Implement precautions to prevent disease transmission.

Offer the client frequent fluids and ice chips.

Answer and Explanation

The Correct Answer is C

A. Developing a plan for increasing activity and mobility is important but is not the immediate priority during the prodromal stage of an infection.
B. Discharge planning and teaching are relevant for patient management but not the priority during the early stages of infection.
C. Implementing precautions to prevent disease transmission is crucial during the prodromal stage, as this is when the infection may be most contagious. Preventing the spread of infection is the top priority.
D. Offering fluids and ice chips helps with comfort and hydration but does not address the prevention of disease transmission.

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Correct Answer is B

Explanation

A. While applying a barrier ointment is important for preventing further skin breakdown, it does not address the immediate need to assess the severity of existing damage.
B. Determining the size and depth of skin breakdown is crucial for assessing the severity of the pressure injury and planning appropriate treatment. Accurate assessment helps in selecting the right interventions and monitoring the progression of the wound.
C. Completing a functional assessment of the client's self-care abilities is important for overall care planning but should follow the initial assessment of the skin breakdown to ensure immediate needs are addressed.
D. Establishing a toileting schedule is a preventive measure for future incontinence but does not address the current skin breakdown that needs immediate assessment and treatment.

Correct Answer is []

Explanation

Overflow urinary incontinence: The client's condition, which includes wet clothes and sheets with a small volume of urine voided, suggests overflow urinary incontinence, where the bladder is not completely emptied and leaks small amounts of urine.
Place an incontinence containment product under the client: This action helps manage urinary incontinence by absorbing leaked urine and keeping the client dry, thereby preventing skin breakdown and discomfort.
Provide skin care: Regular skin care is essential to prevent skin irritation, breakdown, and potential infections, especially when the client is incontinent.
Intake and output: Monitoring intake and output is crucial in assessing the client's fluid balance and urinary function, ensuring that the incontinence is managed effectively.
Skin integrity: Monitoring skin integrity is necessary to identify any signs of pressure ulcers or skin breakdown, which can result from prolonged exposure to moisture due to incontinence.

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During the prodromal stage of an infection, which is the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?

Correct Answer is B

Explanation

Correct Answer is []

Explanation

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