A 36 y.o. woman who has had no prenatal care comes into the hospital in active labor for her fourth child. She has vesicles evident on her perineum. The following nursing actions are appropriate to protect the unborn baby and the staff, EXCEPT:

Correct Answer: D

Rationale: When a woman with vesicles on her perineum comes into the hospital in active labor, it is important to take precautions to protect the unborn baby and the staff. However, applying antibiotic ointment to the vesicles and placing the mother in reverse isolation is not appropriate in this situation. This is because her condition is most likely due to herpes simplex virus (HSV) infection, which can be transmitted to the baby during birth leading to severe complications. Placing the mother in reverse isolation can increase the risk of transmission to the healthcare staff as well. Instead, notifying the obstetrician and nurse midwife about the vesicles as soon as possible is crucial for proper management and preparing for the possibility that the baby may be delivered by cesarean section is important to reduce the risk of transmission during vaginal birth. Maintaining standard precautions is essential to prevent the spread of infection.

Correct Answer: C

Rationale: Monitoring urinary output every hour is crucial in assessing the adequacy of fluid replacement in a client with full-thickness burns. Burn injuries can result in a significant loss of fluid and electrolytes due to increased capillary permeability and excessive fluid shift from the intravascular space to the interstitial space. Adequate fluid replacement is essential to maintain tissue perfusion, prevent hypovolemia, and support organ function. By closely monitoring the urinary output every hour, the nurse can assess renal perfusion, fluid balance, and the effectiveness of fluid resuscitation. A decrease in urinary output can indicate inadequate fluid replacement, while an increase may suggest fluid overload. This information is important in guiding adjustments to the fluid replacement therapy to ensure optimal outcomes for the client. Weights, blood pressure measurements, and assessment of peripheral edema are also important data to monitor in a burn client, but urinary output is the most significant indicator of fluid balance in

Correct Answer: A

Rationale: Clients at risk for hypovolemia, which is a condition characterized by low blood volume, should be advised to avoid alcohol and caffeine. Alcohol and caffeine are known to have diuretic effects, which can further deplete the body's fluid volume and worsen the condition. By avoiding alcohol and caffeine, clients can help maintain adequate fluid levels in the body and reduce the risk of exacerbating hypovolemia. Additionally, it is important for clients at risk for hypovolemia to stay hydrated by consuming adequate amounts of water or other hydrating fluids.

Correct Answer: D

Rationale: The elderly patient who is receiving a diuretic for fluid overload would benefit most from a capped IV catheter used intermittently rather than continuously. Diuretics cause the body to expel excess fluid, so the patient may require intermittent IV fluid replacement to maintain hydration while avoiding overloading the system with excessive fluids. By using the IV catheter intermittently, healthcare providers can closely monitor the patient's fluid status and adjust fluid administration as needed to prevent dehydration or fluid overload. This approach allows for more precise management of the patient's fluid balance compared to continuous IV infusion.

Correct Answer: D

Rationale: Washing hands frequently is an important preventive factor that the nurse should teach a client with rhinitis. Rhinitis is characterized by inflammation of the mucous membrane lining the nose, leading to symptoms such as a runny or stuffy nose. Rhinitis can be caused by viruses, bacteria, allergens, or irritants. By washing hands frequently, the client can reduce the risk of coming into contact with these pathogens and reduce the likelihood of exacerbating their symptoms or developing complications. Handwashing is a simple yet effective way to prevent the spread of infections and maintain good overall health.