A nurse is caring for a 62-year-old client with manifestations of an infection.
Which of the following actions should the nurse take? (Select all that apply.)
Encourage the client to increase fluid intake.
Wear a mask when caring for the client.
Prepare to administer an antibiotic to the client.
Place the client in a private room.
Place the client on contact precautions.
Correct Answer : A,B,D
A. Encourage the client to increase fluid intake: This is important to prevent dehydration, which can be a complication of influenza.
B. Wear a mask when caring for the client: Influenza is a highly contagious virus, and wearing a mask can help prevent the spread of infection.
C. Prepare to administer an antibiotic to the client: Antibiotics are not typically used to treat influenza, which is a viral infection. However, if a bacterial infection develops as a complication, antibiotics may be necessary.
D. Place the client in a private room: Isolating the client in a private room can help prevent the spread of influenza to other patients and healthcare workers.
E. Place the client on contact precautions: Influenza is primarily spread through respiratory droplets, so droplet precautions are appropriate. Contact precautions are not necessary for influenza.
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Related Questions
Correct Answer is C
Explanation
A. Inserting a new indwelling urinary catheter could introduce new pathogens and increase the risk of infection rather than reduce it. Indwelling catheters are a known risk factor for urinary tract infections and should be avoided if possible.
B. Collecting blood cultures is an important diagnostic step, especially if sepsis is suspected. However, this action alone does not directly reduce the risk of septic shock. It is a part of the process but not the most immediate intervention.
C. Initiating intravenous (IV) antibiotics is the most critical intervention to reduce the risk of septic shock. Prompt administration of antibiotics can help control the infection before it progresses to sepsis, making this the priority action.
D. Obtaining placement of an intravenous access for fluid administration is necessary for managing sepsis or septic shock, but the first step should be administering antibiotics to treat the infection causing the sepsis. Fluid administration supports blood pressure and circulation but does not directly address the underlying infection.
Correct Answer is D
Explanation
A. Protective isolation is not directly related to the symptoms of ecchymoses and petechiae but is more relevant for preventing infections in immunocompromised clients.
B. Measures to prevent venous thromboembolism are not the immediate concern given the bleeding symptoms; instead, managing platelet levels and bleeding risks is more critical.
C. Droplet precautions are not indicated based on the described symptoms, which are more related to bleeding disorders rather than infectious conditions requiring droplet precautions.
D. Checking the client's most recent platelet level is the most appropriate action because ecchymoses and petechiae are signs of potential thrombocytopenia (low platelet count), which is common in leukemia. Monitoring platelet levels will help determine if there is a need for interventions to address bleeding risks.
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