A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection. Which response should the nurse provide?
Advise the client that once symptoms occur it is too late to receive an influenza vaccination.
Explain to the client that antibiotics are not useful in treating viral infections such as influenza.
Refer the client to the healthcare provider at the clinic to obtain a medication prescription.
Instruct the client that over-the-counter medications are sufficient to manage influenza symptoms.
The Correct Answer is C
Choice A rationale
Advising the client that it is too late to receive an influenza vaccination once symptoms occur is correct, but it does not address the client’s question about oseltamivir.
Choice B rationale
Explaining that antibiotics are not useful in treating viral infections is correct, but it does not address the client’s question about oseltamivir.
Choice C rationale
Referring the client to the healthcare provider to obtain a medication prescription is the most appropriate response. Oseltamivir is an antiviral medication that can be effective if started within 48 hours of symptom onset.
Choice D rationale
Instructing the client that over-the-counter medications are sufficient to manage influenza symptoms is not appropriate, as oseltamivir can help reduce the severity and duration of the illness if taken early.
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Correct Answer is ["A","D"]
Explanation
Choice A rationale:
Enalapril is an ACE inhibitor used to manage hypertension. While it is generally safe, in the context of pneumonia, it can potentially cause complications such as hypotension, especially if the patient becomes septic or dehydrated. Additionally, ACE inhibitors can cause a persistent cough, which might be confused with or exacerbate the symptoms of pneumonia.
Choice B rationale:
Admitting the patient to the medical floor is appropriate given the diagnosis of pneumonia and the patient’s symptoms. Hospitalization allows for close monitoring and administration of necessary treatments.
Choice C rationale:
Sending blood for a complete blood count and electrolytes is standard practice to assess the patient’s overall health and identify any potential complications such as electrolyte imbalances or infection severity.
Choice D rationale:
Supplemental oxygen at 10 L/min via nasal cannula is quite high and typically not the first choice for pneumonia patients. High-flow oxygen therapy or non-invasive ventilation might be more appropriate if the patient requires such high levels of oxygen. Generally, nasal cannulas are used for lower flow rates (up to 6 L/min), and higher flow rates can cause discomfort and nasal dryness.
Choice E rationale:
Ibuprofen is commonly used to manage fever and pain in pneumonia patients. It helps reduce fever and alleviate discomfort, which can improve the patient’s overall condition.
Choice F rationale:
Continuous pulse oximetry is appropriate for monitoring the patient’s oxygen saturation levels, especially given the initial low oxygen saturation on room air.
Choice G rationale:
Vital signs every 4 hours is a standard practice for monitoring patients with pneumonia to detect any changes in their condition promptly.
Choice H rationale:
A chest X-ray is essential for diagnosing and assessing the extent of pneumonia. It helps in identifying the presence of infiltrates, consolidation, or other complications.
Correct Answer is D
Explanation
Choice A rationale
Determining the neurological baseline prior to the fall is important but not the immediate priority. The client’s current confusion and projectile vomiting suggest a potential acute condition that needs immediate assessment.
Choice B rationale
Determining the client’s last dose of corticosteroids is relevant for managing multiple sclerosis but does not address the immediate concern of confusion and vomiting.
Choice C rationale
Administering a PRN IV antiemetic as prescribed can help manage vomiting but does not address the underlying cause of the symptoms.
Choice D rationale
Completing a head-to-toe neurological assessment is the priority intervention. The client’s confusion and projectile vomiting could indicate increased intracranial pressure or another acute neurological condition that requires immediate attention.