Very hard

A patient has a severe headache, fever, neck stiffness, and sensitivity to light. The patient is alert with a stable airway and breathing pattern. What should the nurse do first?

Correct answer: A. Place the patient in a private room and initiate droplet precautions

  • A. Place the patient in a private room and initiate droplet precautions
  • B. Give oral fluids and reduce the lighting in the room
  • C. Obtain routine blood cultures before taking precautions
  • D. Encourage walking to assess the patient's balance

Explanation

The findings suggest possible meningitis, so preventing respiratory transmission is an immediate priority while urgent assessment and treatment are arranged. Droplet precautions should not be delayed for routine investigations or comfort measures.

Submitted by a TestUstad contributor and published by the TestUstad editorial teamLast updated
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About Clinical Judgement and Prioritisation

Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.

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50 free Clinical Judgement and Prioritisation MCQs from International Nursing Practice, each with the correct answer and an explanation. Unlimited attempts, no account needed.

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