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 B
Explanation
Choice A reason: This is not an appropriate action because asking the client's health care surrogate for permission to withhold nourishment can violate the client's autonomy and dignity. The nurse should respect the client's wishes and preferences regarding end-of-life care and document them clearly.
Choice B reason: This is an appropriate action because providing regular oral care for the client with a moist swab can prevent dryness, cracking, or infection of the mouth and lips and enhance comfort and quality of life. The nurse should also apply lip balm or petroleum jelly as needed.
Choice C reason: This is not an appropriate action because requesting a prescription for IV fluids can cause fluid overload, edema, or dyspnea in the dying client and prolong their suffering. The nurse should follow the provider's orders regarding hydration and nutrition and monitor the client's fluid balance status.
Choice D reason: This is not an appropriate action because explaining the importance of oral hydration to the client can be perceived as coercive or insensitive and cause distress or guilt in the dying client. The nurse should acknowledge the client's decision and provide emotional support and education.
Correct Answer is C
Explanation
Choice A reason: This is not an appropriate action to take first because pulling the fire alarm panel can alert other staff and personnel about the fire and activate the emergency response system, but it does not address the immediate safety and well-being of the client who is exposed to smoke and flames. The nurse should pull the fire alarm panel after removing the client from the room.
Choice B reason: This is not an appropriate action to take first because obtaining a fire extinguisher can help extinguish or contain the fire and prevent it from spreading to other areas, but it does not address the immediate safety and well-being of the client who is exposed to smoke and flames. The nurse should obtain a fire extinguisher after removing the client from the room.
Choice C reason: This is an appropriate action to take first because removing the client from the room can protect them from smoke inhalation, burns, or injuries and ensure their safety and well-being. The nurse should remove the client from the room as quickly and safely as possible and follow the RACE protocol (Rescue, Alarm, Contain, Extinguish).
Choice D reason: This is not an appropriate action to take first because closing the door to the client's room can help contain the fire and prevent it from spreading to other areas, but it does not address the immediate safety and well-being of the client who is exposed to smoke and flames. The nurse should close the door to the client's room after removing them from the room.
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