What is the most important nursing action in caring for a patient who has just recovered from rheumatic fever?
Educate the patient on the necessity of continuous antibiotic prophylaxis.
Inform the patient about the importance of ongoing anticoagulation.
Instruct the patient on the need to adhere to standard infection control procedures.
Guide the patient on how to manage their physical activity.
The Correct Answer is A
Choice A rationale
Education on the necessity of continuous antibiotic prophylaxis is crucial for patients who have just recovered from rheumatic fever. Rheumatic fever is an inflammatory disease that can develop as a complication of untreated or inadequately treated strep throat or scarlet fever.
Patients who have had rheumatic fever are at risk of getting it again if they have another strep infection. Continuous antibiotic prophylaxis can prevent recurrent infections and the development of rheumatic heart disease.
Choice B rationale
While anticoagulation therapy may be necessary for some patients with heart conditions, it is not typically the most important nursing action for a patient who has just recovered from rheumatic fever. Rheumatic fever can cause inflammation and damage to the heart valves, but it does not typically cause blood clots, which are the primary reason for anticoagulation therapy.
Choice C rationale
Adherence to standard infection control procedures is important for all patients, but it is not the most important nursing action for a patient who has just recovered from rheumatic fever. The primary concern for these patients is preventing recurrent strep infections, which can be achieved through continuous antibiotic prophylaxis.
Choice D rationale
While physical activity management may be part of the overall care plan for a patient who has just recovered from rheumatic fever, it is not typically the most important nursing action. The primary concern for these patients is preventing recurrent strep infections, which can be achieved through continuous antibiotic prophylaxis.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s important to inquire about an allergy to iodine in a patient who has undergone an angiogram, it’s not typically the priority for assessing and documenting for this patient after the procedure. An allergy to iodine would be more relevant before the procedure, as iodine-based contrast dye is often used during an angiogram.
Choice B rationale
Checking peripheral pulses in the affected leg is typically a priority when caring for a patient who has undergone an angiogram. This is because the procedure involves inserting a catheter into a blood vessel in the leg. Checking the peripheral pulses can help assess for potential complications such as a blood clot or decreased blood flow to the leg.
Choice C rationale
Monitoring for decreased blood pressure is important in a patient who has undergone an angiogram, but it’s not typically the priority for assessing and documenting for this patient after the procedure. While changes in blood pressure can occur after any medical procedure, other assessments such as checking peripheral pulses in the affected leg are typically more directly related to potential complications of an angiogram.
Choice D rationale
Tracking fluid intake is an important part of overall patient care, but it’s not typically the priority for assessing and documenting for a patient who has undergone an angiogram. Other assessments such as checking peripheral pulses in the affected leg are typically more directly related to potential complications of an angiogram.
Correct Answer is A
Explanation
Choice A rationale
Providing a pressure-reducing mattress, while important for preventing pressure ulcers, is not directly related to improving gas exchange in the lungs. Therefore, it would be considered the least priority intervention for a nursing diagnosis of impaired gas exchange related to fluid in the alveoli.
Choice B rationale
Administering oxygen and monitoring for dry nasal mucus membranes is a crucial intervention for a patient with impaired gas exchange. Oxygen therapy can help increase the amount of oxygen in the blood and alleviate symptoms of hypoxemia.
Choice C rationale
Encouraging the client to turn, deep breathe, cough, and use the incentive spirometer can help improve lung ventilation, promote the clearance of secretions, and prevent atelectasis, thereby improving gas exchange.
Choice D rationale
Placing the client in Fowler’s position can help improve lung expansion and gas exchange by reducing pressure on the diaphragm, making it easier for the patient to breathe.
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