Question

A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days.

The nurse is reviewing the client's medical record. Which of the following actions should the nurse take?
Select all that apply.

Nurses' Notes
1000:
Client reports sore throat, productive cough with yellow-colored mucus, and fever for the past 3 days. Client has swollen lymph nodes. Client also reports headache that, "won't go away." Client's face is flushed and diaphoretic. Throat culture and blood work obtained as prescribed.

Vital Signs
1000:
Blood pressure 132/68 mm Hg, Heart rate 99/min, Respiratory rate 20/min, Temperature 38.3° C (101° F), Oxygen saturation 96% on room air

Diagnostic Results
1100:
Positive throat culture for streptococci bacteria.


A. Request a prescription for an antibiotic medication.
B. Apply oxygen at 2 L/min via nasal cannula.
C. Initiate droplet precautions.
D. Wear a mask within 1 m (3 feet) of the client.
E. Place the client in a negative airflow room.
F. Apply a mask on the client when they leave their room.

Answer 1

The nurse should request a prescription for an antibiotic, initiate droplet precautions, and wear a mask within 1 m (3 feet) of the client, due to the confirmed streptococcal infection.

Step-by-step explanation:

When admitting a client who reports symptoms such as a sore throat, productive cough, fever, swollen lymph nodes, and a headache, the nurse should take several actions based on the clinical information provided. According to the diagnostic results, a positive throat culture for streptococci bacteria suggests that the client has a bacterial infection, likely streptococcal pharyngitis, also known as strep throat.

The appropriate actions the nurse should take include:

• A. Request a prescription for an antibiotic medication: Since the client has a confirmed bacterial infection, an antibiotic is indicated to treat streptococcal infection.
• C. Initiate droplet precautions: Streptococcal pharyngitis is transmitted through respiratory droplets, so precautions are necessary to prevent the spread.
• D. Wear a mask within 1 m (3 feet) of the client: To protect oneself and limit the spread of infection, wearing a mask when in close proximity to the client is essential.

Option B, applying oxygen, is not indicated unless the client is showing signs of hypoxemia or respiratory distress, which the vital signs do not suggest. Option E, placing the client in a negative airflow room, is not necessary for streptococcal infections as they do not require airborne precautions. Lastly, Option F, applying a mask on the client when they leave their room, is a standard droplet precaution, making it a good practice.