# A nurse is caring for a 68-year-old patient diagnosed with influenza A who presents with high fever, severe body aches, and fatigue for the past 48 hours. Which nursing intervention should be the priority to address potential complications?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541867  
> language: ko  
> subject: Adult Health

## 문제

A nurse is caring for a 68-year-old patient diagnosed with influenza A who presents with high fever, severe body aches, and fatigue for the past 48 hours. Which nursing intervention should be the priority to address potential complications?

## 보기

1. Administer oseltamivir (Tamiflu) as prescribed within the first 48 hours of symptom onset **✔ 정답**
2. Encourage increased fluid intake to prevent dehydration
3. Implement strict isolation precautions to prevent transmission
4. Provide comfort measures including rest and analgesics for body aches

**정답: 1**

## 해설

Oseltamivir is the priority as it must be given within 48 hours of symptom onset for optimal antiviral efficacy, especially in high-risk elderly patients. Other interventions like hydration and comfort measures are supportive but secondary.

## 심화 해설

Clinical Judgment
This question assesses clinical prioritization and time-sensitive intervention. The key is the Critical Cue of a '68-year-old elderly patient' and '48 hours since symptom onset.' For Influenza A, the effectiveness of oseltamivir depends heavily on administration within 48 hours of symptom onset. Missing this time window drastically reduces the drug's efficacy. While other interventions are all important, administering the antiviral is the top priority due to this **irreversible time constraint**.

Memory Tip:
**T**ime for **T**amiflu! The most critical factor in influenza management is **T**ime. Remember to administer within 48 hours.

KR vs US:
In Korea, prescribing antivirals upon influenza diagnosis is common, but in NGN/US exams, 'timely administration of an already prescribed medication' is often prioritized higher than 'reporting' such as Notify HCP!. If a medication is prescribed, administering it is the nurse's core responsibility.

## 임상 시나리오

Clinical Practice Guide
When managing influenza patients, it is also important to implement Droplet Precautions. Wearing a mask, maintaining a distance of at least 1 meter, and hand hygiene are essential. Acetaminophen or ibuprofen can be used to manage high fever and pain, and recommending fluid intake to prevent dehydration is an essential supportive treatment.

Caution:
In SATA (Select All That Apply) questions, if asked "What interventions are needed for an influenza patient?", options 1, 2, 3, and 4 **can all be correct**. However, in a question like this that asks "What is the priority initial intervention?", be careful of the trap where you must select **one time-sensitive intervention**.

## 핵심 개념

- **Influenza A** — It is an influenza A virus, a major causative pathogen of seasonal epidemics. It causes high fever, muscle pain, fatigue, and respiratory symptoms.
- **Oseltamivir** — It is an antiviral drug in the neuraminidase inhibitor class. It works by inhibiting the release of influenza virus from infected cells, and its effectiveness is maximized when administered within 48 hours of symptom onset.
- **Dehydration** — Dehydration. A state of insufficient body fluids due to high fever and poor appetite, which can commonly occur in influenza patients, making encouragement of fluid intake an important nursing intervention.
- **Droplet Precautions** — Droplet precautions. This is an infection control method applied to diseases transmitted through large droplets (>5㎛), such as influenza, requiring mask wearing and maintaining close distance.
- **Clinical Prioritization** — Clinical priority setting. This is a thought process that ranks multiple nursing problems or interventions to address the most urgent and important ones first for patient safety and outcomes.

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