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A client with a temperature of 39°C (102.2°F) and a rash is being evaluated. Which condition should the nurse consider?

A.

Meningococcal meningitis.

B.

Urinary tract infection.

C.

Gastroenteritis.

D.

Osteoarthritis.

Answer and Explanation

The Correct Answer is A

Choice A rationale

 

Meningococcal meningitis can present with a high fever (39°C or 102.2°F) and a rash, indicating a severe bacterial infection.

 

Choice B rationale

 

Urinary tract infections typically present with urinary symptoms, not a rash.

 

Choice C rationale

 

Gastroenteritis presents with gastrointestinal symptoms, not a rash.

 

Choice D rationale

 

Osteoarthritis is a degenerative joint disease and does not cause fever or rash.
 


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Correct Answer is A

Explanation

Choice A rationale

Administering antipyretic medication as prescribed is a priority intervention for a client with a body temperature of 38°C (100.4°F). Antipyretics help reduce fever and provide comfort to the patient. They work by inhibiting the production of prostaglandins, which are involved in the fever response.

Choice B rationale

Encouraging fluid intake to prevent dehydration is also important, but it is not the priority intervention. Adequate hydration helps maintain fluid balance and supports the body’s ability to regulate temperature.

Choice C rationale

Monitoring vital signs every 4 hours is essential for assessing the patient’s condition, but it is not an intervention that directly addresses the fever. It helps track the patient’s response to treatment and detect any changes in their condition.

Choice D rationale

Applying a cooling blanket to reduce fever can be effective, but it is typically used when antipyretic medications are not sufficient or contraindicated. Cooling measures help lower body temperature through conduction and evaporation.

Correct Answer is C

Explanation

Choice A rationale

Wearing an N95 mask is appropriate for airborne precautions, such as tuberculosis, but not specifically for MRSA, which requires contact precautions.

Choice B rationale

Wearing a facemask is suitable for droplet precautions, such as influenza, but MRSA is primarily spread through direct contact, not droplets.

Choice C rationale

Using a separate disposable blood pressure cuff for patients with draining wounds helps prevent the spread of MRSA. MRSA can be transmitted via contaminated medical equipment.

Choice D rationale

Strict hand washing measures are essential but should be performed more frequently than once every 8-hour shift. Hand hygiene should be practiced before and after patient contact.

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