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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: A blood pressure measurement of 80/60 mm Hg is significantly low and may indicate hypotension, which can lead to symptoms such as dizziness, fainting, or shock. This requires immediate action to assess and manage the client's condition to prevent complications.
Choice B reason: A blood pressure measurement of 140/90 mm Hg indicates hypertension, which is a concern but does not require immediate emergency intervention. It requires follow-up and management to prevent long-term health issues.
Choice C reason: A blood pressure measurement of 130/85 mm Hg is considered elevated but not critically high. It is important to monitor and manage, but it does not require immediate emergency action.
Choice D reason: A blood pressure measurement of 120/90 mm Hg is slightly elevated diastolic pressure but not critically so. It is important to monitor, but it does not necessitate immediate emergency intervention.

A. Ask the client about any changes in vision. B. Notify the charge nurse of the finding. C. Assist the client to a semi-Fowler's position. D. Assess the client using the Glasgow Coma Scale.

Correct Answer is B

Explanation

Choice A reason: Asking the client about any changes in vision can provide valuable information regarding the client's subjective experience and any potential progression of cataracts. However, given the observation of milky white pupils, which may indicate a more serious issue such as advanced cataracts or another underlying condition, it is crucial to take immediate and appropriate action. While gathering subjective data is important, notifying the charge nurse ensures that the finding is promptly addressed by the healthcare team.
Choice B reason: Notifying the charge nurse of the finding is the most appropriate action in this scenario. The observation of milky white pupils in a client with cataracts could indicate significant changes or complications that require further evaluation and potential intervention. By promptly reporting this finding to the charge nurse, the practical nurse ensures that the client receives timely and appropriate care, including potential diagnostic tests and consultations with specialists if necessary.
Choice C reason: Assisting the client to a semi-Fowler's position can be beneficial for comfort and to facilitate breathing, especially in bedfast clients. However, this action does not directly address the observation of milky white pupils. The immediate priority is to notify the charge nurse to ensure that the finding is properly evaluated and managed. Positioning the client can be done as part of routine care, but it is not the most urgent response to the observed change.
Choice D reason: Assessing the client using the Glasgow Coma Scale (GCS) is appropriate for evaluating the level of consciousness and neurological status. However, in this context, the observation of milky white pupils is more likely related to an ocular condition rather than a neurological issue. While it is always important to monitor the client's overall status, the immediate priority is to report the finding to the charge nurse for appropriate ocular assessment and management.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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