Try Naxlex NCLEX-RN (Free-Trial)

Patient Data
The nurse is considering the care of plan. Which intervention(s) should be a part of the client's plan of care? Select all that apply.

Provide tepid baths

Monitor temperature

Provide quiet activity

Suggest cool-mist vaporizer

Apply cold compresses

Isolate for 14 days

Assess urinary output

Provide supplemental oxygen

Administer antipyretics

Answer and Explanation

Correct Answer : B,C,D,G,I

Rationale:
A. Provide tepid baths: Tepid sponging or baths are no longer recommended as a primary fever treatment because they can cause shivering, which actually increases the body's core temperature (metabolic heat production).

B. Monitor temperature: Measles is associated with high, persistent fevers, and close temperature monitoring is essential to evaluate response to antipyretics and to detect worsening infection or complications.

C. Provide quiet activity: Measles causes significant fatigue and systemic illness, and minimizing stimulation helps conserve energy, reduce metabolic demands, and promote recovery in an ill infant.

D. Suggest cool-mist vaporizer: A cool-mist vaporizer can help soothe inflamed airways, loosen secretions, and improve comfort when cough and upper respiratory symptoms are present.

E. Apply cold compresses: Cold compresses can induce shivering and vasoconstriction, increasing metabolic demand and discomfort, making them inappropriate for fever management in infants.

F. Isolate for 14 days: Airborne isolation for measles is required from symptom onset through 4 days after rash appearance, not for a fixed 14-day period.

G. Assess urinary output: Fever and decreased oral intake place the infant at risk for dehydration, making urine output a key indicator of hydration status and renal perfusion.

H. Provide supplemental oxygen: Oxygen therapy is not indicated unless the child demonstrates hypoxemia or signs of respiratory distress, which are not present in this assessment.

I. Administer antipyretics: Antipyretics such as acetaminophen reduce fever, improve comfort, and decrease metabolic demands, forming a core component of supportive measles management.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:
A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus: Education on infection control is important, but immediate isolation measures take priority to prevent potential transmission in the clinic setting. Patient teaching alone does not contain exposure risk.

B. Move the client to a private room, keep the door closed, and initiate droplet precautions: Implementing isolation and droplet precautions immediately protects healthcare personnel and other clients from potential COVID-19 exposure. Rapid containment is the priority when a patient presents with symptoms consistent with a contagious respiratory virus.

C. Assist the client to recall everyone possibly exposed since onset of symptoms: Contact tracing is part of public health management, but it is secondary to immediate infection control and isolation. Ensuring staff and patient safety takes precedence over exposure recall.

D. Place the nasal swab specimen for COVID-19 directly into a biohazard bag: Proper specimen handling is necessary to prevent contamination, but it is not the first priority. Immediate patient isolation and precautions should occur before specimen processing.

A. Assist with ambulation in the hallway. B. Teach to sleep in a side-lying position. C. Encourage active range of motion exercises. D. Provide a bedside commode for toileting.

Correct Answer is D

Explanation

Rationale:
A. Assist with ambulation in the hallway: Ambulation increases oxygen demand and cardiac workload. While mobility is important for pneumonia recovery, unassisted or frequent hallway ambulation may overtax a client with heart failure.

B. Teach to sleep in a side-lying position: Side-lying may provide comfort, but it does not significantly reduce cardiac workload. Upright or semi-Fowler positions are more effective in decreasing preload and improving breathing.

C. Encourage active range of motion exercises: Active exercises increase metabolic demand and cardiac workload. While beneficial for maintaining joint mobility, they should be limited or modified in clients with compromised cardiac function.

D. Provide a bedside commode for toileting: Using a bedside commode minimizes exertion and prevents unnecessary strain from walking to the bathroom. Reducing physical activity helps lower cardiac workload, supporting oxygenation and hemodynamic stability in a client with heart failure.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Patient Data The nurse is considering the care of plan. Which intervention(s) should be a part of the client's plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care?

Correct Answer is D

Explanation

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (D5W) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)

A client with a hip fracture is requesting pain medication prior to being repositioned in the bed. To assess the quality of the client's pain, which approach should the nurse use?

Patient Data For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

The nurse is assessing a client who is reporting a severe headache. During the physical assessment, which finding should the nurse interpret as a possible indication of meningitis?

The nurse is caring for a client with a fractured femur. Following removal of traction and the application of a full leg cast, which action should the nurse prioritize?

Patient Data
The nurse is considering the care of plan. Which intervention(s) should be a part of the client's plan of care? Select all that apply.