A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse recommend?
Measure the client's intake and output every 8 hr.
Dim the lighting in the client's room.
Monitor the client's temperature every 6 hr.
Initiate contact precautions for the client.
The Correct Answer is B
Choice A Reason:
Measuring the client's intake and output every 8 hours is a general nursing intervention but might not be specifically pertinent to managing viral meningitis.
Choice B Reason:
Dim the lighting in the client's room is correct. Meningitis often causes sensitivity to light (photophobia) due to the inflammation of the meninges surrounding the brain and spinal cord. Dimming the lighting in the client's room helps reduce discomfort and sensitivity to light, which is a common symptom of meningitis.
Choice C Reason:
Monitoring the client's temperature every 6 hours is a routine nursing practice, but in viral meningitis, more frequent temperature monitoring might be necessary, especially if the client shows signs of fever or instability.
Choice D Reason:
Initiating contact precautions for viral meningitis is not typically necessary because it's usually transmitted through respiratory secretions. Standard precautions for infection control, including proper hand hygiene, are usually sufficient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Replace the unit when the drainage chamber is full is correct. Regularly emptying the drainage chamber when it becomes full is essential to ensure the drainage system functions properly and continues to effectively remove fluids or air from the chest cavity.
Choice B Reason:
Clamp the tube for 30 min every 8 hr. is incorrect.
Clamping a chest tube without a specific medical order or indication can lead to complications such as a buildup of pressure within the chest cavity or potential damage to the lungs. It's generally not a routine action to clamp the tube without proper instruction.
Choice C Reason:
Pin the tubing to the client's bed sheets is incorrect. Pinning the tubing to the bed sheets can cause tension on the chest tube, leading to accidental dislodgment or obstruction. The tubing should be secured but not pinned to prevent inadvertent movement.
Choice D Reason:
Monitor for at least 150 mL of drainage every hour is incorrect. There isn't a standard or prescribed amount of drainage that should occur hourly. The nurse should monitor the drainage rate and characteristics but shouldn't expect a specific volume within a set timeframe. Monitoring for excessive or decreased drainage and changes in characteristics is crucial, but an hourly volume expectation isn't appropriate.
Correct Answer is C
Explanation
Choice A Reason:
Chill the dialysate prior to infusion. Generally, the dialysate used in peritoneal dialysis is warmed to body temperature before infusion to enhance comfort and prevent abdominal discomfort. Chilling the dialysate can cause discomfort and is not a standard practice in peritoneal dialysis.
Choice B Reason:
Monitor the client for diarrhea. While gastrointestinal symptoms might occur in some individuals undergoing peritoneal dialysis due to changes in fluid balance, diarrhea is not a typical or expected outcome. However, monitoring for any unusual gastrointestinal symptoms or changes in bowel habits is part of holistic client care.
Choice C Reason:
Weigh the client before and after the treatment. Weighing the client before and after peritoneal dialysis is a critical step to assess the effectiveness of the treatment. The difference in weight helps determine how much fluid was removed during the dialysis process, providing valuable information about the treatment's efficacy and the client's fluid status.
Choice D Reason:
Use clean gloves when handling dialysate bags. Maintaining aseptic technique during peritoneal dialysis is crucial to prevent infections. The use of clean gloves (not sterile gloves, unless otherwise specified) when handling dialysate bags helps minimize the risk of contamination, ensuring the safety of the procedure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today