A nurse enters a client’s room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

Choice A reason: Fluconazole treats fungal infections, not RSV, a viral respiratory illness. Antivirals like ribavirin might apply, but antifungals don’t. Scientifically, this mismatches RSV’s etiology, as it’s a paramyxovirus, rendering fluconazole ineffective and irrelevant for managing this preschooler’s condition.

Choice B reason: Monitoring urine for protein assesses kidney function, unrelated to RSV, which affects lungs. Proteinuria isn’t a typical RSV sign. Scientifically, this lacks relevance, as RSV causes respiratory distress, not renal complications, making it an unnecessary action here.

Choice C reason: An X-ray of the neck targets croup or epiglottitis, not RSV, which affects lower airways. RSV needs chest imaging if severe. Scientifically, neck imaging misaligns with RSV’s pathophysiology, wasting resources when lung assessment is more pertinent.

Choice D reason: Droplet precautions prevent RSV spread via respiratory droplets, critical in preschoolers who aerosolize virus easily. Scientifically, this aligns with infection control, as RSV’s high contagiousness requires masks and isolation to protect others, a primary nursing action per guidelines.

Choice A reason: Cardiac medications don’t contraindicate varicella vaccine, a live virus. Unless immunocompromised (e.g., via steroids), cardiac conditions don’t impair immunity enough for risk. Scientifically, this lacks evidence as a barrier, as the vaccine’s safety profile supports use in stable cardiac cases without immune suppression.

Choice B reason: Chemotherapy suppresses immunity, making live vaccines like varicella dangerous due to risk of unchecked viral replication. This contraindication is scientifically grounded, as immunocompromised states (e.g., from cancer treatment) heighten infection risk, necessitating delay until immune recovery per vaccination guidelines.

Choice C reason: Two diarrhea stools in a day isn’t a contraindication unless severe or linked to immunosuppression. Mild illness doesn’t preclude live vaccines; varicella can be given unless fever or systemic compromise exists. Scientifically, this is insufficient to halt immunization based on current evidence.

Choice D reason: Clear rhinorrhea from a cold isn’t a contraindication for varicella vaccine. Mild respiratory symptoms without fever don’t impair immune response significantly. Scientifically, guidelines allow vaccination during minor illnesses, as it poses no increased risk, distinguishing it from severe immune deficits.