A nurse is admitting a client who has measles and a persistent cough. Which of the following actions is a priority for the nurse to take?

Place the client in airborne isolation.

Advise the family members not to bring flowers into the room.

Obtain a sputum sample for culture.

Place the client on contact precaution.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Placing the client in airborne isolation is a priority because measles is highly contagious and spread through airborne droplets. Airborne precautions are necessary to prevent the transmission of pathogens that can remain suspended in the air for longer periods. Measles is known for its high infectivity, and isolating the client in a negative pressure room equipped with HEPA filtration can help prevent the spread of the virus to other patients and healthcare workers.

Choice B rationale:

While advising family members not to bring flowers into the room is a reasonable infection control measure, it is not the priority action in this scenario. The immediate concern is to prevent the spread of the highly contagious measles virus through airborne transmission.

Choice C rationale:

Obtaining a sputum sample for culture is not the priority action in this situation. Measles is a viral infection, and sputum cultures are typically used to identify bacterial infections. Additionally, the primary mode of transmission for measles is through airborne droplets, so preventing its spread takes precedence over obtaining a sputum sample.

Choice D rationale:

Placing the client on contact precaution is not the correct choice for managing measles. Measles is primarily transmitted through the airborne route, so airborne precautions, not contact precautions, are necessary to prevent its transmission.

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Correct Answer is C

Explanation

Choice A rationale:

Providing wound irrigation might be necessary during the dressing change, but it is not the first action the nurse should take. First, the nurse should ensure they have all the necessary supplies to prevent interruptions during the procedure.

Choice B rationale:

While avoiding accidentally removing the drain is important, it is not the first action the nurse should take. Ensuring that all supplies are gathered and ready will help facilitate a smooth and organized dressing change.

Choice C rationale:

Gathering supplies is the priority in this situation. Having all the needed supplies readily available ensures that the dressing change can be carried out efficiently and without unnecessary delays.

Choice D rationale:

Providing analgesic medication as ordered by the provider is important for the patient's comfort during the procedure. However, it should not be the first action the nurse takes. First, the nurse should ensure that they have all the necessary supplies to conduct the dressing change safely.

A. Sanguineous. B. Serous. C. Purulent. D. Serosanguineous.

Correct Answer is D

Explanation

Choice A rationale:

Sanguineous. Sanguineous drainage is typically bright red and consists of fresh blood. It indicates active bleeding from the wound. In this case, the drainage described is not bright red but rather light red-pink, suggesting that it is not purely sanguineous.

Choice B rationale:

Serous. Serous drainage is thin, watery, and typically clear or slightly yellowish in color. It is a normal part of the wound healing process and is not indicative of active bleeding. However, the drainage described in the question is light red-pink, which is not consistent with serous drainage.

Choice C rationale:

Purulent. Purulent drainage is thick, often opaque, and can range in color from yellow to green. It indicates the presence of infection in the wound. The description of watery light red-pink drainage does not align with the characteristics of purulent drainage.

Choice D rationale:

Serosanguineous. Serosanguineous drainage is a combination of serous and sanguineous fluids. It appears as a thin, watery drainage that is pink-tinged due to the presence of a small amount of blood. This description matches the observed drainage in the question. Serosanguineous drainage is common during the initial stages of wound healing and is considered a normal part of the process.

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A nurse is admitting a client who has measles and a persistent cough. Which of the following actions is a priority for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

Correct Answer is C

Explanation

A nurse on the Medical-Surgical unit is assessing a patient's wound dressing, and observes a watery light red-pink drainage. The nurse should document this drainage as which of the following?

Correct Answer is D

Explanation

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