A nurse is caring for a client.

Nurses Notes: Day 1: Custom Nursing Assessment.

Vital Signs: Diagnostic Results: Client is admitted with a 2-day history of headache, muscle aches, fever, sore throat, and fatigue.

Prepare to administer an antibiotic to the client.

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

Choice A rationale
Encouraging the client to increase fluid intake is correct. Increasing fluid intake helps to maintain hydration, which is essential for the body to function properly, especially when the client is experiencing fever and muscle aches. Hydration helps to thin mucus, making it easier to expel, and supports the immune system in fighting off infection.
Choice B rationale
Placing the client in a private room is correct. A private room helps to prevent the spread of infection to other patients and healthcare workers. This is particularly important when the client has symptoms such as fever, sore throat, and fatigue, which could indicate a contagious illness.
Choice C rationale
Placing the client on contact precautions is incorrect. Contact precautions are typically used for infections that are spread by direct contact with the patient or their environment, such as MRSA or C. difficile. The symptoms described (headache, muscle aches, fever, sore throat, and fatigue) do not necessarily indicate an infection that requires contact precautions.
Choice D rationale
Wearing a mask when caring for the client is correct. Wearing a mask helps to prevent the transmission of respiratory infections, which can be spread through droplets when the client coughs or sneezes. This is especially important when the client has symptoms such as a sore throat and fever, which could indicate a respiratory infection.

Choice A rationale
Urinary output is an important postoperative assessment, but it is not the highest priority for a client who has undergone a thoracotomy and lobectomy. Monitoring urinary output helps assess kidney function and fluid balance, but it does not directly address the respiratory status, which is critical in this case. The primary concern after thoracotomy and lobectomy is ensuring adequate oxygenation and ventilation, as the surgery directly impacts the lungs and respiratory function.
Choice B rationale

Pain level is a significant postoperative assessment, as effective pain management is crucial for recovery. However, it is not the highest priority in this scenario. While managing pain is essential to prevent complications such as atelectasis (collapse of part of the lung) due to shallow breathing, the immediate focus should be on assessing and maintaining adequate respiratory function. Pain management can be addressed once the client’s respiratory status is stabilized.
Choice C rationale
Chest tube drainage is a critical postoperative assessment for clients who have undergone thoracotomy and lobectomy. Monitoring chest tube output helps detect complications such as bleeding or pneumothorax (air in the pleural space). However, it is not the highest priority compared to arterial blood gases assessment. While chest tube drainage provides valuable information about the client’s condition, arterial blood gases assessment directly measures the client’s oxygenation and ventilation status, which is paramount in the immediate postoperative period.
Choice D rationale
Arterial blood gases (ABG) assessment is the highest priority for a client who is postoperative following a thoracotomy and lobectomy. ABG analysis provides crucial information about the client’s oxygenation, ventilation, and acid-base balance. This assessment helps detect hypoxemia (low blood oxygen levels), hypercapnia (elevated carbon dioxide levels), and respiratory acidosis, which are critical concerns after lung surgery. Ensuring adequate oxygenation and ventilation is the top priority to prevent respiratory complications and support the client’s recovery.