A nurse is caring for a client whose throat culture is positive for group A streptococcus 24 hours after a rapid strep test (RST) was negative. Which of the following actions is the nurse's priority?
Reinforce teaching about gargling with warm saline several times daily.
Ask the client to identify friends and family who have been in close contact.
Instruct the client to take antipyretics as directed for elevated temperature.
Notify the client to return to the clinic for initiation of antibiotic therapy.
The Correct Answer is D
Choice A reason:
While gargling with warm saline can provide symptomatic relief for a sore throat, it does not address the underlying bacterial infection. Therefore, it is not the priority action once a diagnosis of group A streptococcus has been confirmed.
Choice B reason:
Identifying close contacts is important for public health tracking and potentially preventing the spread of the infection. However, the immediate priority for the client is the initiation of treatment to address the infection.
Choice C reason:
Taking antipyretics can help manage fever and provide comfort to the client. While managing symptoms is important, it is secondary to initiating antibiotic therapy, which addresses the cause of the symptoms.
Choice D reason:
The priority action is to notify the client to return to the clinic for initiation of antibiotic therapy. Group A streptococcus is a bacterial infection that requires antibiotics for treatment. Prompt initiation of antibiotics is crucial to prevent complications and promote recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Immunoglobulin G (IgG) is the most common type of antibody found in blood circulation and is involved in the body's immune response to fight infections. However, IgG is not typically associated with allergic reactions, which are immediate hypersensitivity reactions.
Choice B reason:
Immunoglobulin A (IgA) plays a critical role in mucosal immunity and is found in high concentrations in the mucous membranes, particularly those lining the respiratory passages and gastrointestinal tract. Like IgG, IgA is not primarily responsible for the allergic response seen in conditions such as seasonal allergies.
Choice C reason:
Immunoglobulin M (IgM) is usually the first antibody produced by the immune system when it detects an infection. IgM antibodies are larger and are involved in the primary immune response but are not the antibodies that mediate typical allergic reactions.
Choice D reason:
Immunoglobulin E (IgE) is the antibody that plays a central role in the pathophysiology of allergic diseases, including seasonal allergies. IgE antibodies are produced as a response to allergens and are responsible for the symptoms of an allergic reaction. An elevation in IgE levels typically indicates a positive result for an allergy test such as RAST.
Correct Answer is C
Explanation
Choice A reason:
Bathroom privileges after premedication are not typically restricted unless the premedication impairs the client's ability to ambulate safely. However, it is important to ensure that the client does not fall or injure themselves due to the effects of the medication.
Choice B reason:
Drinking 8 oz of water is generally not advised immediately before surgery due to the risk of aspiration during anesthesia. Clients are usually instructed to fast, which includes not drinking any liquids, for a certain period before surgery.
Choice C reason:
Preoperative diazepam may be administered 30 minutes before surgery to help reduce anxiety and induce sedation. Diazepam is a benzodiazepine that can calm the client and facilitate a smoother induction of anesthesia.
Choice D reason:
Enema administration is not a standard preoperative procedure for a client undergoing a cholecystectomy unless there is a specific indication. The primary focus is on preventing infection and managing pain.
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