The practical nurse (PN) is caring for a client admitted with a diagnosis of herpes zoster. The client has draining lesions and reports that the affected area is painful. Which action should the PN take first?
Administer a prescribed analgesic.
Measure the client's temperature.
Initiate contact isolation precautions.
Apply cool, wet compresses to the lesions.
The Correct Answer is C
Choice A reason: Administering a prescribed analgesic is important for managing the client's pain and improving their comfort. However, before addressing the client's pain, it is crucial to ensure that appropriate infection control measures are in place. Herpes zoster (shingles) is a contagious condition, especially when there are draining lesions. The first priority is to prevent the spread of the infection to other clients and healthcare workers.
Choice B reason: Measuring the client's temperature is important for monitoring for signs of systemic infection, such as fever. While this is a necessary assessment, it is not the most immediate priority. Ensuring that appropriate isolation precautions are in place takes precedence to prevent the transmission of the infection.
Choice C reason: Initiating contact isolation precautions is the most critical action to take first. Herpes zoster can be spread through direct contact with the fluid from the lesions. Implementing contact isolation precautions, such as wearing gloves and gowns, and placing the client in a private room, helps to contain the infection and protect others. This is the first step in managing the client's condition and ensuring a safe environment for all.
Choice D reason: Applying cool, wet compresses to the lesions can help soothe the affected area and provide some relief from the pain and discomfort associated with herpes zoster. However, this is not the immediate priority. The first action should be to implement isolation precautions to prevent the spread of the infection. Once isolation measures are in place, the nurse can then focus on providing symptomatic relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hydrocortisone is a corticosteroid that can cause fluid retention and increase blood pressure in some individuals. It is important for the PN to monitor the client's blood pressure and educate them about this potential side effect.
Choice B reason: Tiotropium bromide is a bronchodilator used to manage asthma and chronic obstructive pulmonary disease (COPD). While it is not commonly associated with increasing blood pressure, the PN should still be aware of any potential side effects and monitor the client's blood pressure.
Choice C reason: Ethinyl estradiol/norethindrone is a combination oral contraceptive that contains estrogen and progestin. Estrogen can cause blood vessels to constrict, leading to an increase in blood pressure. The PN should educate the client about this potential side effect and monitor their blood pressure regularly.
Choice D reason: Pseudoephedrine is a decongestant that can cause vasoconstriction and increase blood pressure. It is important for the PN to inform the client about this potential side effect and monitor their blood pressure closely.
Choice E reason: Albuterol sulfate is a bronchodilator used to relieve asthma symptoms. While it can cause some cardiovascular side effects, such as increased heart rate, it is not typically associated with a significant increase in blood pressure. The PN should still monitor the client's blood pressure and be aware of any potential side effects.
Correct Answer is A
Explanation
Choice A reason: Driving a car is an activity that requires physical and mental focus, which can be impaired following surgery. The client recovering from a transurethral prostatectomy might experience discomfort, pain, or the effects of anesthesia, which could affect their ability to drive safely. Additionally, there is a risk of increased pressure on the surgical site while sitting for prolonged periods, which can impact the healing process. Limiting this activity until after the first postoperative visit ensures that the healthcare provider can assess the client's recovery and provide appropriate guidance on when it is safe to resume driving.
Choice B reason: Eating high-fiber foods is generally encouraged to prevent constipation, which is a common issue post-surgery. Fiber helps maintain regular bowel movements and can reduce the strain during defecation. This is beneficial for clients recovering from a transurethral prostatectomy as straining can increase pressure on the surgical site. Therefore, there is no need to limit the intake of high-fiber foods; rather, it should be reinforced as a positive dietary habit during the recovery period.
Choice C reason: Kegel exercises are recommended to strengthen the pelvic floor muscles, which can aid in improving urinary control post-surgery. These exercises are an integral part of the recovery process for clients undergoing prostate surgery and can significantly enhance bladder function. Thus, Kegel exercises should not be limited but should be encouraged as part of the client's postoperative care plan.
Choice D reason: Walking around the house is a low-impact activity that can promote circulation and prevent complications such as deep vein thrombosis (DVT). It also helps in maintaining overall mobility and can aid in the recovery process. Limiting such light physical activity is unnecessary, as it can have several benefits for the client during the postoperative period. Encouraging gentle movement is generally advantageous for recovery.
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