A nurse is caring for a 62-year-old client with manifestations of an infection.

Exhibits

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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Decreasing the client's oral fluid intake is inappropriate in the postoperative period following a TURP, as adequate hydration is essential to prevent clot formation and maintain catheter patency. Limiting fluids could lead to increased clot formation and obstructed flow.
B. Weighing the client every evening is not a relevant intervention in the immediate postoperative period of TURP. Weight monitoring is more critical for fluid balance in chronic conditions such as heart failure or renal disease, not in the acute setting after TURP.
C. Monitoring urine output every 6 hours is insufficient for a client receiving continuous bladder irrigation. Immediate postoperative care requires more frequent monitoring to detect potential complications such as clot retention or hemorrhage.
D. Reminding the client that he might feel a constant urge to void is essential. Continuous bladder irrigation can cause bladder spasms and a persistent sensation of needing to urinate, which is common after TURP. This helps the client understand and cope with these sensations, reducing anxiety and unnecessary concern.

A. Apply heated compress to the knee. B. Assess client's activated partial thromboplastin time (aPTT). C. Administer low-dose aspirin. D. Prepare for autologous blood transfusion.

Correct Answer is B

Explanation

B. Assessing the client's activated partial thromboplastin time (aPTT) is important to monitor the effectiveness of treatment and manage bleeding risk. Hemophilia A is characterized by a deficiency in clotting factor VIII, which prolongs the aPTT.
A. Applying heated compresses is not recommended for hemarthrosis; instead, cold compresses should be used to reduce bleeding and swelling.
C. Low-dose aspirin is contraindicated for clients with hemophilia because it can further inhibit platelet function and increase bleeding risk.
D. Autologous blood transfusion is not typically required for hemophilia; factor replacement therapy is the standard treatment.

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A nurse is caring for a 62-year-old client with manifestations of an infection. Exhibits Which of the following actions should the nurse take? (Select all that apply.)

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A nurse is caring for a 62-year-old client with manifestations of an infection.

Exhibits

Which of the following actions should the nurse take? (Select all that apply.)