A patient has been recently diagnosed with an upper respiratory infection. His brother arrives and would like to visit. The patient says he is not feeling strong enough to have visitors. Which symptom would indicate to the nurse that the client is developing a complication?
Dry, occasional cough.
Temperature or Febrile 103 degrees F (39.4 degrees C)
Clear, watery drainage from the nose
Scratchy throat
The Correct Answer is B
A. Dry, occasional cough: A dry, occasional cough is a common symptom of upper respiratory infections and may not necessarily indicate a complication.
B. Temperature or Febrile 103 degrees F (39.4 degrees C): A high fever (over 100.4 degrees F or 38 degrees C) is a concerning symptom that may indicate the development of a complication such as pneumonia or a secondary bacterial infection.
C. Clear, watery drainage from the nose: Clear, watery drainage from the nose is typically associated with viral upper respiratory infections and may not necessarily indicate a complication.
D. Scratchy throat: A scratchy throat is a common symptom of upper respiratory infections and may not necessarily indicate a complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Document the client's history of skin allergies: While important for the client's overall care, documenting the history of skin allergies is not the priority when assessing a new skin lesion.
B. Photograph the lesion for the client's medical record: Documenting the appearance of the lesion is important for the client's medical record, but it is not the priority when initially assessing the lesion.
C. Identify when the client first noticed the lesion: The priority is to gather information about the onset and characteristics of the lesion to determine its potential severity and urgency of intervention.
D. Instruct the client on the use of daily sunscreen products: While sun protection is important for skin health, it is not the priority when assessing a new skin lesion.
Correct Answer is B
Explanation
A. A person with diabetes who requires hospitalization for cellulitis: Cellulitis may not necessarily be a healthcare-associated infection unless it developed as a complication during the hospitalization.
B. Pneumonia in a hospitalized patient: Pneumonia acquired during a hospital stay is considered a healthcare-associated infection (HAI) because it develops after 48 hours of hospital admission.
C. Chronic urinary tract infection for a homebound patient: A chronic urinary tract infection in a homebound patient is not automatically considered a healthcare-associated infection unless it can be directly linked to healthcare interventions or devices.
D. A sexually transmitted infection in a healthy young adult: Sexually transmitted infections are not healthcare-associated infections as they are typically acquired through sexual contact rather than healthcare settings.
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