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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:
Using an antibiotic ointment is not typically recommended as a preventive measure for skin integrity during radiation therapy. Antibiotic ointments are used to treat bacterial infections, and their use should be directed by a healthcare provider if an infection is present or there is skin breakdown.

Choice B reason:
It is important not to apply heat to the area of irradiation as heat can increase skin irritation and the risk of burns in the treated area. Patients undergoing radiation therapy are advised to avoid heat sources, including heating pads, hot water bottles, and direct sunlight, to prevent further damage to the skin.

Choice C reason:
Lubricating the skin with hypoallergenic lotion can help maintain skin integrity by keeping it moisturized. However, it is crucial to use lotions that are free of metals, alcohol, perfumes, and dyes, as these can react with radiation and cause skin irritation. Lotions should be applied after radiation therapy sessions and not immediately before treatment.

Choice D reason:
The instruction not to wash the area of irradiation is incorrect. It is essential to keep the skin clean to reduce the risk of infection. Patients should gently wash the irradiated area with lukewarm water and mild soap, and pat the area dry with a soft towel. They should avoid scrubbing or using harsh soaps that can irritate the skin.

A. A client who has an autoimmune disorder. B. A 40-year-old client with hypoglycemia. C. A client who does not get much sleep. D. A 26-year-old female client who has never given birth.

Correct Answer is B

Explanation

Choice A reason:
While autoimmune disorders are associated with type 1 diabetes, where the immune system attacks the pancreas, they are not typically a direct risk factor for type 2 diabetes. Type 2 diabetes is more closely related to lifestyle factors and insulin resistance.

Choice B reason:
A 40-year-old client with hypoglycemia may be at risk for developing type 2 diabetes. Hypoglycemia can be a sign of pre-diabetes or insulin resistance, where the body's response to insulin is not as effective, leading to fluctuations in blood sugar levels. As individuals age, their risk for type 2 diabetes increases, particularly if they have other risk factors such as a sedentary lifestyle, overweight, or a family history of diabetes.

Choice C reason:
Lack of sleep can contribute to the development of type 2 diabetes by affecting the body's ability to regulate glucose and by increasing insulin resistance. However, without additional risk factors, it is not as strong a predictor of type 2 diabetes as the presence of hypoglycemia or other metabolic conditions.

Choice D reason:
Having never given birth is not a recognized risk factor for type 2 diabetes. While gestational diabetes is a risk factor for developing type 2 diabetes later in life, the absence of pregnancy does not increase the risk.

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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?

Nursing Test Bank

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