The school nurse identifies 12 students with confirmed cases of influenza A. The families of the children are advised to keep the children home for a minimum of 5 to 7 days. Which of the following is an appropriate action by the nurse?

Choice A reason:

Assisting a client with a bed bath who has a history of falls is important for maintaining hygiene and preventing skin breakdown. However, this task does not address an immediate physiological need. While it is essential to ensure the safety of clients with a history of falls, this task can be scheduled after more urgent needs are met. The priority in nursing care is to address tasks that have the most immediate impact on a client’s health and safety.

Choice B reason:

Providing a snack to a diabetic client who is feeling lightheaded is the most urgent task. Lightheadedness in a diabetic client can be a sign of hypoglycemia, which requires immediate intervention to prevent serious complications such as loss of consciousness or seizures. Hypoglycemia occurs when blood sugar levels drop too low, and providing a quick source of glucose can help stabilize the client’s condition. This task addresses an immediate physiological need and is critical for the client’s safety and well-being.

Choice C reason:

Feeding a client who has bilateral casts due to upper arm fractures is necessary to ensure the client receives adequate nutrition. However, this task does not address an immediate threat to the client’s health. While it is important to assist clients who are unable to feed themselves, this task can be performed after more urgent needs are addressed. Prioritizing tasks that address immediate physiological needs is essential in nursing care.

Choice D reason:

Ambulating a postoperative client for the first time is important for preventing complications such as deep vein thrombosis, pneumonia, and muscle weakness. Early ambulation is a key component of postoperative care and helps promote recovery. However, this task can be scheduled after addressing more immediate physiological needs. Ensuring the safety and stability of clients with urgent conditions takes precedence over routine postoperative care activities.

Choice A reason:

Limiting fluid intake to prevent incontinence is not recommended as it can lead to dehydration and other complications. Proper hydration is essential for overall health, and other strategies should be used to manage incontinence.

Choice B reason:

Administration of antispasmodic medication can help manage bladder spasms and incontinence, but it is not the highest priority intervention. While medication can be part of the treatment plan, preventing skin breakdown is more critical in the immediate care of a client with reflex incontinence.

Choice C reason:

Kegel exercises to strengthen the pelvic floor can be beneficial for managing incontinence, but they may not be effective for clients with paralysis following a spinal cord injury. These exercises require voluntary muscle control, which may be impaired in such clients.

Choice D reason:

Regular perineal care to prevent skin breakdown is the highest priority intervention for a client with reflex incontinence. Incontinence can lead to skin irritation, breakdown, and infection if not managed properly. Ensuring good perineal hygiene helps prevent these complications and promotes overall skin health.