A nurse is caring for a 30-year-old patient diagnosed with influenza A. The patient has been experiencing moderate fever, cough, and sore throat for the past 3 days. Which nursing intervention should be the priority?
1Administer aspirin for fever reduction and pain relief
2Encourage increased fluid intake and monitor for signs of dehydration✓ 정답
3Place the patient in a supine position to promote rest
4Restrict all visitors to prevent disease transmission
해설
Hydration is the priority to prevent dehydration from fever and decreased intake, which can lead to serious complications. Other options like aspirin or visitor restriction are less critical.
Clinical Judgment
This question assesses your ability to apply the principles of prioritization and the ABCs (basic physiological needs). The patient is at high risk for dehydration due to high fever and severe symptoms. High fever increases metabolic rate and insensible fluid loss, while fatigue and discomfort reduce oral intake. Therefore, encouraging increased fluid intake and monitoring for signs of dehydration is the most important intervention. This is fundamental nursing care that maintains the fluid and electrolyte balance essential for sustaining life, prevents complications, and aids recovery.
Memory TipFlu + Fever = Fluids First!
KR vs US
In Korea, prescribing and administering antipyretics for influenza patients is very common, but the NCLEX/NGN prioritizes meeting basic physiological needs (fluids, rest) and safety (especially the risk of Reye syndrome) over medication administration. Also, while infection control (isolation, handwashing) is important in US nursing, in this case, the patient's direct physiological instability (risk of dehydration) is considered the more urgent issue.
Clinical Practice Guide
When caring for patients with influenza A, prioritize fluid intake, and electrolyte drinks may be recommended. Regularly assess vital signs, especially heart rate and blood pressure, and accurately record intake and output (I&O). Evaluate skin turgor, oral mucosa condition, and the degree of sunken eyes to determine the level of dehydration.
Caution
Option 1 (administering aspirin) is a trap. Administering aspirin to children and adolescents with influenza or chickenpox symptoms carries the risk of a fatal complication called Reye syndrome. It is often not recommended for adults either, and administering medication for fever/pain relief is a lower priority than basic interventions such as fluid intake.
Influenza A — A type of influenza virus that causes seasonal outbreaks, a highly contagious acute respiratory infection causing high fever, muscle aches, fatigue, and respiratory symptoms.
Dehydration — A condition caused by excessive loss of body fluids or inadequate intake. Symptoms include dry mouth, decreased urine output, reduced skin turgor, tachycardia, and hypotension.
Reye Syndrome — A rare but fatal condition associated with aspirin use during recovery from viral infections (influenza, chickenpox), characterized by acute brain swelling and fatty liver.
Fluid Intake and Output (I&O) — Nursing activity that quantitatively records and monitors fluid intake and output from all routes to assess the patient's fluid balance status.
Droplet Precautions — Infection control measures applied to infectious diseases (e.g., influenza, meningococcal meningitis) that can be transmitted through large droplets (>5μm) produced when coughing, sneezing, or talking. Includes wearing a mask, maintaining a distance of at least 1m, etc.