Nclex Questions Management of Care Related

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What action should the emergency triage nurse take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?

  • A. Place the client in isolation until further assessment is completed.
  • B. Seclude the client from other clients and visitors.
  • C. Perform no intervention until test results confirm a diagnosis.
  • D. Don personal protective equipment immediately.
Correct Answer: B

Rationale: The correct action for the emergency triage nurse to take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting is to seclude the client from other clients and visitors. These symptoms are suggestive of tuberculosis, a highly infectious disease. By secluding the client, the nurse can prevent the potential spread of the infection to others. Donning personal protective equipment, including gown, gloves, and a mask, is crucial when providing care to the client, but the immediate priority is to prevent the spread of infection by isolating the client. Placing the client in isolation until further assessment is completed ensures that the client is kept away from others until a proper diagnosis and treatment plan can be established, reducing the risk of transmission. Performing no intervention until test results confirm a diagnosis is inappropriate as immediate isolation is necessary in suspected cases of highly infectious diseases like tuberculosis.