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 maintaining direct pressure over the site can help stop the bleeding by compressing the blood vessels and promoting clot formation. The nurse should apply firm and continuous pressure for at least 15 minutes or until the bleeding stops.
Choice B reason: This is not an appropriate action because reinforcing the dressing over the site can obscure the assessment of the bleeding and increase the risk of infection. The nurse should change the dressing only when it becomes saturated or as prescribed.
Choice C reason: This is not an appropriate action because obtaining a radial pulse is not relevant to the management of bleeding from a small laceration on the arm. The nurse should monitor the client's vital signs, especially blood pressure and heart rate, to detect signs of shock or blood loss.
Choice D reason: This is not an appropriate action because checking whether the bleeding has stopped can disrupt the clotting process and cause more bleeding. The nurse should avoid lifting or removing the dressing until the bleeding stops or as prescribed.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because lime ice popsicle is a clear liquid that can help hydrate the client and soothe the stomach. Clear liquids are recommended for the first 24 hours after gastroenteritis to prevent dehydration and nausea.
Choice B reason: This is not a good choice because vanilla pudding is a dairy product that can be hard to digest and cause diarrhea or cramps. Dairy products should be avoided until the client has no symptoms for at least 48 hours.
Choice C reason: This is not a good choice because orange juice is acidic and can irritate the stomach and cause vomiting or heartburn. Acidic foods and drinks should be avoided until the client has no symptoms for at least 48 hours.
Choice D reason: This is not a good choice because cream of broccoli soup is high in fat and fiber that can be hard to digest and cause gas or bloating. High-fat and high-fiber foods should be avoided until the client has no symptoms for at least 48 hours.
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