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 D
Explanation
Choice A rationale
The SA node sending an electrical signal greater than 100/min describes sinus tachycardia, not atrial fibrillation. In atrial fibrillation, the issue is not with the SA node but with the atria’s chaotic electrical activity.
Choice B rationale
An early electrical signal occurring before the expected SA node signal describes a premature atrial contraction (PAC), not atrial fibrillation. PACs are isolated events, whereas atrial fibrillation involves sustained irregular electrical activity.
Choice C rationale
Slow electrical transmission through the AV node describes a heart block, not atrial fibrillation. In atrial fibrillation, the problem is with the atria’s rapid and irregular electrical signals, not the AV node’s conduction speed.
Choice D rationale
Atrial fibrillation is characterized by rapid, chaotic, and irregular electrical signals in the atria. This leads to an irregular and often rapid heart rate, causing symptoms like dizziness and palpitations.
Correct Answer is B
Explanation
Choice A rationale
Doubling the dose of warfarin if a dose is missed is incorrect because it can lead to an increased risk of bleeding. Warfarin is an anticoagulant, and maintaining a consistent blood level is crucial to avoid complications. Doubling the dose can cause the blood to become too thin, leading to severe bleeding events.
Choice B rationale
Using an electric razor while on warfarin is correct because it helps prevent cuts and bleeding. Warfarin increases the risk of bleeding, and using an electric razor reduces the chance of nicks and cuts that can occur with a traditional razor.
Choice C rationale
Increasing fiber intake to reduce constipation is incorrect because warfarin does not typically cause constipation. Fiber intake is generally recommended for overall digestive health, but it is not specifically related to warfarin use.
Choice D rationale
Mild nosebleeds are not common during initial treatment with warfarin. Nosebleeds can indicate that the blood is too thin, which is a sign of over-anticoagulation and requires medical attention.
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