An nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?
Provide the client with antipyretic therapy.
Administer antibiotics to the client.
Increase the client's protein intake.
Teach relaxation breathing to reduce the client's pain.
The Correct Answer is B
Choice A reason: Providing the client with antipyretic therapy is not the nurse's priority. Antipyretic therapy is a treatment that lowers the body temperature and reduces fever. Fever is a common symptom of acute osteomyelitis, which is a bacterial infection of the bone and bone marrow. Antipyretic therapy may help to relieve the discomfort and inflammation caused by fever, but it does not address the underlying cause of the infection.
Choice B reason: Administering antibiotics to the client is the nurse's priority. Antibiotics are medications that kill or inhibit the growth of bacteria. Antibiotics are the main treatment for acute osteomyelitis, as they target the specific type of bacteria that is causing the infection. Antibiotics can prevent the spread of the infection to other bones or organs and reduce the risk of complications, such as chronic osteomyelitis, septic arthritis, or sepsis.
Choice C reason: Increasing the client's protein intake is not the nurse's priority. Protein intake is a nutritional factor that affects the wound healing and immune system. Protein is composed of amino acids, which are the building blocks of cells and tissues. Protein intake can enhance the repair and regeneration of the bone and the soft tissues that are damaged by the infection. Protein intake can also support the immune system's ability to fight off the infection. However, protein intake alone is not sufficient to treat acute osteomyelitis, as it does not eliminate the bacteria that are causing the infection.
Choice D reason: Teaching relaxation breathing to reduce the client's pain is not the nurse's priority. Relaxation breathing is a technique that involves deep and slow breathing that helps to relax the body and mind. Relaxation breathing can help to reduce the pain and stress that are associated with acute osteomyelitis. Pain is a common symptom of acute osteomyelitis, which is caused by the inflammation and pressure on the bone and the surrounding tissues. Relaxation breathing can help to ease the pain and improve the mood and quality of life of the client. However, relaxation breathing alone is not enough to treat acute osteomyelitis, as it does not address the source of the pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A reason: A temperature of 101.3 degrees Fahrenheit is a sign of fever, which is a common symptom of infection. Clients with AIDS have a weakened immune system and are more susceptible to opportunistic infections. Fever indicates that the body is trying to fight off an infection.
Choice B reason: An oxygen saturation of 97% on room air is within the normal range and does not indicate infection. Oxygen saturation measures the percentage of hemoglobin that is bound to oxygen in the blood. A low oxygen saturation may indicate respiratory problems, such as pneumonia, which is a common infection in clients with AIDS.
Choice C reason: A respiratory rate of 22 breaths per minute is slightly above the normal range of 12 to 20 breaths per minute, but it does not necessarily indicate infection. Respiratory rate may vary depending on factors such as activity level, stress, pain, or anxiety. A high respiratory rate may indicate respiratory distress, which could be caused by infection or other conditions.
Choice D reason: Purulent drainage is a thick, yellowgreen, or brown pus that indicates infection. It may come from a wound, an abscess, or a body cavity. Purulent drainage is a sign of inflammation and infection and should be reported to the health care provider.
Choice E reason: A client's ability to ambulate 20 feet is not related to infection. Ambulation is a measure of mobility and function and may be affected by factors such as pain, fatigue, or muscle weakness. Ambulation does not reflect the presence or absence of infection.
Correct Answer is A
Explanation
Choice A reason: Administering topical hydrocortisone is the appropriate nursing intervention, because it can help reduce the inflammation and itching of the skin lesions that are common in SLE. SLE is a chronic autoimmune disease that causes the immune system to attack various organs and tissues, such as the skin, joints, kidneys, heart, and blood vessels. Hydrocortisone is a type of corticosteroid that can suppress the immune response and relieve the symptoms of SLE.
Choice B reason: Applying cold therapy to the extremities is not the appropriate nursing intervention, because it can worsen the circulation and sensation of the fingers and toes that are affected by Raynaud's phenomenon, which is a complication of SLE. Raynaud's phenomenon is a condition that causes the blood vessels in the extremities to narrow and spasm in response to cold or stress, resulting in numbness, pain, and color changes. Cold therapy can trigger or aggravate Raynaud's phenomenon.
Choice C reason: Administering antibiotics is not the appropriate nursing intervention, because it is not indicated for SLE, unless there is a secondary infection. SLE is not caused by bacteria, but by the abnormal activity of the immune system. Antibiotics are drugs that can kill or inhibit the growth of bacteria, but they have no effect on the underlying cause of SLE. Antibiotics can also have side effects, such as allergic reactions, gastrointestinal disturbances, or resistance.
Choice D reason: Encouraging ultraviolet (UV) light exposure is not the appropriate nursing intervention, because it can trigger or worsen the skin lesions and the disease activity of SLE. UV light is a type of radiation that can damage the DNA and the cells of the skin, causing inflammation, redness, and blistering. UV light can also stimulate the production of antibodies and cytokines that can attack the organs and tissues of the body.
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