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.)
Encourage the client to increase fluid intake.
Place the client in a private room.
Place the client on contact precautions.
Wear a mask when caring for the client.
Correct Answer : A,B,D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Giving the child acetaminophen for discomfort is appropriate as it helps manage pain without interfering with the healing process.
Choice B rationale
Keeping the child home for 1 week is not necessary unless there are specific complications or instructions from the healthcare provider.
Choice C rationale
Assisting the child to take a tub bath for the first 3 days is not recommended as it may increase the risk of infection at the catheter insertion site.
Choice D rationale
Offering the child clear liquids for the first 24 hours is not necessary unless there are specific dietary restrictions from the healthcare provider.
Correct Answer is B
Explanation
Choice A rationale
Acetylcysteine is used to treat acetaminophen overdose and does not reverse the effects of heparin.
Choice B rationale
Protamine sulfate is the specific antidote for heparin and is used to reverse its anticoagulant effects.
Choice C rationale
Deferasirox is used to treat chronic iron overload and does not reverse the effects of heparin.
Choice D rationale
Vitamin K is used to reverse the effects of warfarin, not heparin.
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