A nurse is reinforcing teaching with a client who has streptococcal pharyngitis. Which of the following actions is appropriate for the nurse to include in the plan of care?
Place the client in a negative airflow room.
Implement droplet precautions.
Place the client on a fluid restriction.
Obtain a throat culture after the initial dose of antibiotics.
The Correct Answer is B
Choice A reason: This is not an appropriate action for this client because placing them in a negative airflow room is indicated for clients who have airborne infections, such as tuberculosis or measles, that can spread through small particles that remain suspended in air. Streptococcal pharyngitis, also known as strep throat, is caused by bacteria that spread through large respiratory droplets that fall within 3 feet from source.
Choice B reason: This is an appropriate action for this client because implementing droplet precautions can prevent transmission of streptococcal pharyngitis to others by contact with respiratory secretions or contaminated objects. The nurse should wear a surgical mask when entering the client's room and instruct visitors to do so as well. The nurse should also place a mask on the client when transporting them outside their room.
Choice C reason: This is not an appropriate action for this client because placing them on a fluid restriction can cause dehydration and impair mucosal healing. The nurse should encourage the client to drink plenty of fluids, such as water, tea, or broth, to soothe the throat and prevent dryness.
Choice D reason: This is not an appropriate action for this client because obtaining a throat culture after the initial dose of antibiotics can affect the accuracy of the test results and delay diagnosis and treatment. The nurse should obtain a throat culture before starting antibiotics to confirm the presence of streptococcal bacteria and guide antibiotic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because auscultating the client's abdomen for bowel sounds is an assessment that can provide information about the client's bowel motility and function. The nurse should listen for at least 5 minutes in each quadrant and note the frequency, intensity, and quality of bowel sounds.
Choice B reason: This is not an appropriate action to take first because providing privacy with a set time to defecate is an intervention that can promote regular bowel elimination and prevent constipation. The nurse should perform this action after assessing the client's bowel sounds and other factors that may affect defecation, such as pain, medication, diet, and activity.
Choice C reason: This is not an appropriate action to take first because encouraging oral intake of fluids is an intervention that can soften stool and facilitate bowel movement. The nurse should perform this action after assessing the client's bowel sounds and fluid balance status.
Choice D reason: This is not an appropriate action to take first because administering a fiber-based laxative is an intervention that can increase bulk and stimulate peristalsis. The nurse should perform this action after assessing the client's bowel sounds and contraindications for laxatives, such as bowel obstruction, impaction, or perforation.
Correct Answer is D
Explanation
Choice A reason: This is not an immunization that the nurse should identify as needed for this client because measles, mumps, and rubella are viral diseases that can be prevented by vaccination in childhood or early adulthood. The nurse should ask the client about their vaccination history and check their immunity status by blood tests if necessary.
Choice B reason: This is not an immunization that the nurse should identify as needed for this client because human papilloma virus is a sexually transmitted infection that can cause genital warts or cervical cancer and can be prevented by vaccination before sexual activity or exposure. The nurse should educate the client about safe sex practices and screening tests for cervical cancer.
Choice C reason: This is not an immunization that the nurse should identify as needed for this client because inactivated polio virus is a vaccine that protects against poliomyelitis, a viral disease that can cause paralysis or death and can be prevented by vaccination in childhood or early adulthood. The nurse should ask the client about their vaccination history and check their immunity status by blood tests if necessary.
Choice D reason: This is an immunization that the nurse should identify as needed for this client because herpes zoster is a viral disease that causes shingles, a painful rash with blisters that can affect any part of the body and can be prevented by vaccination in older adults. The nurse should recommend that the client receive two doses of herpes zoster vaccine at least 2 months apart.
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