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 A
Explanation
Choice A reason:
Phenytoin is an antiepileptic drug that can be used to treat and prevent seizures. Headache and restlessness could be signs of neurological irritation or an impending seizure, which phenytoin can help to manage. It is important to monitor the client's neurological status closely following hemodialysis, as changes in electrolyte balance can affect neuronal activity.
Choice B reason:
Decreased blood pressure and rapid pulse are not typical indications for administering phenytoin. These symptoms could indicate hypovolemia or other cardiovascular issues that may occur after hemodialysis, which would require different interventions.
Choice C reason:
Muscle cramps and chest heaviness are not indications for phenytoin administration. Muscle cramps can be a common side effect of hemodialysis due to electrolyte shifts, and chest heaviness may indicate cardiovascular strain or other complications.
Choice D reason:
Pain and tingling at the access site are typically related to the vascular access itself and are not treated with phenytoin. These symptoms may require assessment for potential complications such as infection or thrombosis at the access site.
Correct Answer is A
Explanation
Choice A Reason:
The instruction to urinate a small amount into the toilet before collecting the sample is correct because it helps clear the urethra of organisms that could contaminate the specimen. This initial void helps to flush out bacteria that are present at the opening of the urethra.
Choice B Reason:
This choice is incorrect because urine samples should be kept at body temperature and sent to the lab as soon as possible. Cooling the urine can lead to precipitation of solutes and may affect the results of certain tests.
Choice C Reason:
This statement is incorrect. The proper technique for cleansing prior to urine collection is to wipe from front to back, not back to front. Wiping from back to front can contaminate the urine with bacteria from the anal area.
Choice D Reason:
It is advisable not to collect a urine sample during menstruation unless absolutely necessary because menstrual blood can contaminate the urine specimen, leading to inaccurate test results.
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