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?
Monitor for muscle paralysis.
Place in contact isolation.
Check for increased salivation.
Administer clindamycin hydrochloride.
The Correct Answer is A
The nurse should include monitoring for muscle paralysis in the plan of care for a client with botulism poisoning. Botulism is a serious bacterial illness that can cause muscle paralysis and can be life threatening. Monitoring for muscle paralysis is essential for early detection and intervention.
Choice B is incorrect because contact isolation is not necessary for the treatment of botulism.
Choice C is incorrect because increased salivation is not a common symptom of botulism.
Choice D is incorrect because clindamycin hydrochloride is not used to treat botulism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.
Choice C rationale: A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.
Choice A rationale: The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.
Choice B rationale: The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.
Choice D rationale: The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.
Correct Answer is B
Explanation
This finding could indicate the presence of bile leakage, which can occur following a cholecystectomy. The provider should be notified immediately as the client may require further interventions. Incisional pain, shoulder pain, and a dry and intact abdominal dressing are expected findings in the postoperative period.
Choice C, incisional pain 5 out of 10 on a pain scale, is not the correct answer because this level of pain is within the expected range for the postoperative period.
Choice D, abdominal dressing dry and intact, is not the correct answer because this is an expected finding in the postoperative period.
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