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 a sore throat, productive cough with yellow-colored mucus, and fever for the past 3 days. The client has swollen lymph nodes. The client also reports a headache that, won't go away. The 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) Initiate droplet precautions.

B) Administer an antiviral medication.

C) Administer an antibiotic.

D) Isolate the client in a negative pressure room.

Answer 1

The nurse should initiate droplet precautions, administer an antibiotic, and isolate the client in a negative pressure room.

Step-by-step explanation:

The nurse should take the following actions:

1. Initiate droplet precautions: Given the client's symptoms of a sore throat, productive cough, and presence of streptococci bacteria, it is important to implement droplet precautions to prevent the spread of infection. Droplet precautions involve wearing a mask, maintaining a safe distance, and ensuring proper hand hygiene.
2. Administer an antibiotic: The presence of streptococci bacteria in the throat culture indicates a bacterial infection, such as strep throat. To treat the infection, the nurse should administer an appropriate antibiotic as prescribed by the healthcare provider.
3. Isolate the client in a negative pressure room: Since the client has positive throat culture results for streptococci bacteria, it is necessary to isolate the client in a negative pressure room to prevent the spread of the bacteria to others.