A nurse is assisting in developing the plan of care for a client with streptococcal pharyngitis. What is an appropriate action to include in the plan of care?

Place the client in a negative airflow room.

Obtain a throat culture after the initial dose of antibiotics.

Implement droplet precautions.

Place the client on a fluid restriction.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Implement droplet precautions. Streptococcal pharyngitis is a highly contagious infection caused by group A beta-hemolytic streptococcus. Droplet precautions are the appropriate precautionary measures to prevent the spread of the infection. This includes placing the client in a private room or with a client with the same infection, wearing a mask or respirator, and using proper hand hygiene. Option A is incorrect because negative airflow rooms are not required for clients with streptococcal pharyngitis. Option B is incorrect because throat cultures should be obtained before the initial dose of antibiotics. Option D is incorrect because fluid restriction is not a necessary intervention for clients with streptococcal pharyngitis.

Option A - Negative airflow rooms are used for airborne illnesses like tuberculosis.

Option B - Throat culture should be obtained before the initial dose of antibiotics.

Option D - Fluid restriction is not a necessary intervention for clients with streptococcal pharyngitis.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.

Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.

Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.

Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.

A. Check for neck vein distention. B. Offer oral fluids every 4 hr. C. Monitor pulse pressure every 6 hr. D. Limit oral fluids prior to bedtime.

Correct Answer is A

Explanation

Answer is a. Check for neck vein distention.

a. Check for neck vein distention: Correct. Assessing for neck vein distention is an essential intervention for a client receiving IV fluid replacement, especially for dehydration. Neck vein distention can indicate fluid overload, a potential complication of IV fluid therapy. By monitoring for this sign, the nurse can promptly recognize and intervene to prevent fluid overload-related complications such as pulmonary edema and hypertension. Regular assessment of neck vein distention provides valuable information about the client's fluid status and guides adjustments to the IV fluid infusion rate to maintain fluid balance and prevent adverse outcomes.

b. Offer oral fluids every 4 hr: This option is incorrect because offering oral fluids every 4 hours may not be appropriate for a client receiving IV fluid replacement for dehydration. IV fluid replacement is typically indicated when oral rehydration is insufficient or impractical, such as in cases of severe dehydration, altered consciousness, or gastrointestinal disturbances. The frequency and volume of oral fluid intake should be individualized based on the client's condition, fluid requirements, and ability to tolerate oral intake. Therefore, the nurse should prioritize IV fluid therapy and adjust oral fluid intake accordingly based on ongoing assessment of the client's hydration status.

c. Monitor pulse pressure every 6 hr: While monitoring pulse pressure can provide valuable information about fluid status and cardiac function, it may not be as specific or sensitive as other signs such as neck vein distention when assessing for fluid overload in clients receiving IV fluid replacement. Pulse pressure is the difference between the systolic and diastolic blood pressure readings and can be affected by various factors, including cardiac output, vascular resistance, and volume status. However, changes in pulse pressure may not always correlate directly with fluid overload, especially in clients with underlying cardiovascular conditions or receiving vasopressor medications. Therefore, more frequent and comprehensive assessments, including physical examination findings such as neck vein distention, are necessary to evaluate fluid balance accurately.

d. Limit oral fluids prior to bedtime: This option is incorrect because limiting oral fluids prior to bedtime is generally not indicated for dehydrated clients, especially those receiving IV fluid replacement. Restricting fluid intake may exacerbate dehydration and compromise the effectiveness of IV fluid therapy. Instead, the nurse should encourage adequate fluid intake throughout the day and evening to promote hydration and support the client's recovery from dehydration. Individualized fluid management strategies should be based on the client's fluid requirements, renal function, underlying condition, and response to therapy.

In summary, the correct answer is a because checking for neck vein distention is an essential intervention for monitoring fluid status and detecting potential complications such as fluid overload in clients receiving IV fluid replacement for dehydration. This assessment helps ensure safe and effective fluid management and prevents adverse outcomes associated with fluid overload.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assisting in developing the plan of care for a client with streptococcal pharyngitis. What is an appropriate action to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid replacement. Which of the following interventions should the nurse contribute to the plan of care?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is scheduled for a cardiac catheterization. Which of the following should the nurse tell the client to expect during injection of the contrast medium?

A nurse is assisting with the plan of care for a client who has botulism poisoning. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?

A nurse is reinforcing teaching with a client who is recovering from gastroenteritis and is beginning oral intake. Which of the following foods should the nurse recommend?

A nurse is contributing to the plan of care for a client who has an external fixation device in place to treat an open fracture of the tibia and fibula. Which of the following interventions should the nurse include?

A nurse is collecting data from a client about her current pain status. Which of the following questions should the nurse ask to determine the quality of the client's pain?

A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following assessment findings should the nurse report to the provider?

A charge nurse is reinforcing teaching about infection control with a newly licensed nurse. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?