Question

"A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. Client also reports headache that, 'won't go away. Client's face is flushed and diaphoretic. Throat culture and blood work obtained as prescribed.' The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that applies."

A) Administer an antibiotic without waiting for culture results
B) Initiate isolation precautions
C) Encourage the client to continue with regular activities
D) Monitor vital signs closely
E) Provide pain relief for the headache
F) Await the results of the throat culture and blood work before initiating treatment

Answer 1

The nurse should initiate isolation precautions, monitor the client's vital signs closely, and provide pain relief for the headache. It is essential to await the results of the throat culture and blood work before initiating treatment unless clinical guidelines suggest otherwise.

Step-by-step explanation:

In reviewing the client's medical record and symptoms, the nurse should consider appropriate next steps in their care. Given the client's symptoms, it is important to control the infection and provide symptomatic relief, while also confirming the diagnosis with test results. The following actions should be considered:

• Initiate isolation precautions: If there is a suspicion of a contagious infection, it might be necessary to prevent the spread of infection to others, especially in a healthcare setting.
• Monitor vital signs closely: The client's fever and other vital signs need to be carefully watched to detect any changes in their condition.
• Provide pain relief for the headache: Symptomatic treatment can be provided to make the client more comfortable while waiting for a diagnosis.
• Await the results of the throat culture and blood work before initiating treatment: It's important not to administer an antibiotic or other treatments without confirmation of the infection type, unless indicated by clinical guidelines for empiric treatment.

It's important to note that if the client's condition warrants it based on clinical judgment or if the clinical picture is highly indicative of a certain bacterial infection, empiric antibiotic treatment may sometimes be justified before culture results are back. This is especially true in cases of suspected pneumonia or other severe infections as mentioned in the case studies provided. Such actions should be based on established clinical guidelines and protocols.