During the prodromal stage of an infection, which is the priority nursing intervention?

Develop a plan for gradually increasing activity and mobility.

Begin discharge planning and teaching.

Implement precautions to prevent disease transmission.

Offer the client frequent fluids and ice chips.

Answer and Explanation

The Correct Answer is C

A. Developing a plan for increasing activity and mobility is important but is not the immediate priority during the prodromal stage of an infection.
B. Discharge planning and teaching are relevant for patient management but not the priority during the early stages of infection.
C. Implementing precautions to prevent disease transmission is crucial during the prodromal stage, as this is when the infection may be most contagious. Preventing the spread of infection is the top priority.
D. Offering fluids and ice chips helps with comfort and hydration but does not address the prevention of disease transmission.

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Correct Answer is D

Explanation

A. Temperature is important but does not directly address the immediate concern of cyanosis, which suggests possible issues with oxygenation.
B. Blood pressure is also important, but in the context of cyanosis, assessing the respiratory status is more directly related to identifying the cause of decreased oxygenation.
C. Heart rate is crucial for assessing circulatory status, but cyanosis often indicates a problem with oxygenation, making it less immediately relevant compared to respiratory assessment.
D. Respiratory rate should be assessed first as cyanosis can indicate impaired oxygenation, which is often due to respiratory issues. Evaluating the respiratory rate helps determine if there is a problem with breathing or gas exchange that needs immediate attention.

A. Elevate the area and apply light pressure over the site. B. Apply a cold pack to the area for twenty minutes. C. Document the site where the medication was given. D. Notify the healthcare provider of the allergic response.

Correct Answer is C

Explanation

A. Elevating the area and applying light pressure is not appropriate for a small raised area from an intradermal injection, which is usually a normal reaction and not an indication for elevation or pressure.
B. Applying a cold pack is unnecessary and may not be appropriate unless there is significant discomfort or an allergic reaction, which is not suggested by the description of a small, raised area.
C. Documenting the site where the medication was given is important for record-keeping and monitoring the reaction to the intradermal test. This helps in assessing normal reactions versus abnormal ones later.
D. Notifying the healthcare provider of an allergic response should be done if the reaction is severe or unexpected, but a small, round raised area is typically a normal response to an intradermal injection.

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During the prodromal stage of an infection, which is the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

Correct Answer is D

Explanation

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

Correct Answer is C

Explanation

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