1. A client who has recently traveled to China comes to the emergency department (ED)
with increasing shortness of breath and is strongly suspected of
... [Show More] having severe acute
respiratory syndrome (SARS). Which of these prescribed actions will you take first?
1. Infuse normal saline at 75 mL/hr.
2. Obtain blood, urine, and sputum for cultures.
3. Place the client on airborne and contact precautions.
4. Give methylprednisolone (Solu-Medrol) 1 g IV. - 1. Ans: 3. Place the client on
airborne and contact precautions.
Current Centers for Disease Control and Prevention (CDC) guidelines indicate that
rapid implementation of standard, contact, and airborne precautions are needed for any
client suspected of having SARS in order to protect other clients and health care
workers. If an airborne-agent isolation (negative-pressure) room is not available in the
ED, droplet precautions should be initiated until the client can be moved to a negativepressure room. The other actions should also be taken rapidly but are not as important
as preventing transmission of the disease. Focus: Prioritization
2. You are caring for a newly admitted client with increasing dyspnea, hypoxia, and
dehydration who has possible avian influenza ("bird flu"). Which of these prescribed
actions will you implement first?
1. Start oxygen using a nonrebreather mask.
2. Infuse 5% dextrose in water at 100 mL/hr.
3. Administer first dose of oseltamivir (Tamiflu).
4. Obtain blood and sputum specimens for testing. - 2. Ans: 1. Start oxygen using a
nonrebreather mask.
Because the respiratory manifestations associated with avian influenza are potentially
life-threatening, the nurse's initial action should be to start oxygen therapy. The other
interventions should be implemented after addressing the client's respiratory problems.
Focus: Prioritization
3. You are preparing to leave the room after performing oral suctioning on a client who
is on contact and airborne precautions. In which order will you perform the following
actions?... [Show Less]