During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes.

Which nursing intervention has the highest priority?

Assess her feelings about therapeutic abortions in the event the infant has been affected

Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary.

Instruct her to avoid sexual intercourse while active, visible lesions are present.

Determine if the client has taken acyclovir for this outbreak of genital herpes.

Answer and Explanation

The Correct Answer is C

A.   Assess her feelings about therapeutic abortions in the event the infant has been affected. - While important to address concerns, the immediate priority is to manage the current outbreak and prevent transmission.
B.   Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. - Contact tracing is important but not the highest priority in managing the current outbreak.
C.   Instruct her to avoid sexual intercourse while active, visible lesions are present. - This is crucial to prevent transmission of the herpes virus to the sexual partner and to reduce the risk of complications for the pregnancy.
D.   Determine if the client has taken acyclovir for this outbreak of genital herpes. - While important for understanding the treatment history, instructing the client on preventive measures has a higher priority.

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Correct Answer is B

Explanation

A. Missing pulse. - This term implies the complete absence of a pulse, which might not be the case here; the pulse is present but disappears with light pressure.
B. Thready pulse volume. - A thready pulse refers to a weak pulse that is easily obliterated with light pressure. This accurately describes the finding observed by the PN.
C. Light pressure applied to pulse. - This description simply explains the technique used to assess the pulse and does not adequately capture the quality of the pulse.
D. Pulse skips beats. - This term refers to an irregularity in the pulse rhythm, not to the disappearance with light pressure.

A. Document the appearance of the wound as inflamed. B. Report the appearance of the dressing to the charge nurse. C. C Compress the drainage device before closing the tab. D. Clamp the drainage tubing for the next four hours.

Correct Answer is ["B","C"]

Explanation

A. The wound is not inflamed, but rather discharging excessively. The PN should document the amount and color of the drainage, the size and location of the wound, and any signs of infection or complications.
B. The dressing needs to be changed as soon as possible to prevent infection and further blood loss. The charge nurse can also assess the need for additional interventions, such as suturing, hemostasis, or transfusion.
C. Compressing the device creates a vacuum that helps drain the fluid from the wound. The PN should squeeze the device until it is about half full, then close the tab securely.
D. Clamping the tubing can cause a backup of fluid in the wound, which can increase the risk of infection and impair healing. The PN should never clamp the tubing unless instructed by the provider.
E. Removing the device can cause more bleeding and disrupt the healing process. The PN should only remove the device when ordered by the provider or when it is no longer needed.

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During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

Correct Answer is B

Explanation

The practical nurse (PN) observes a client's initial postoperative dressing and drain as seen in the picture. Which follow-up actions should the PN implement? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

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The practical nurse (PN) observes an infant searching for a fallen toy. According to Piaget, which additional finding should the PN correlate with this developmental stage?

During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes.

Which nursing intervention has the highest priority?