A client is admitted to the emergency department with toxic shock syndrome. Which action by the nurse is the most important?
a. Administer IV fluids to maintain fluid and electrolyte balance.
b. Remove the tampon as the source of infection.
c. Collect a blood specimen for culture and sensitivity.
d. Transfuse the client to manage low blood count.
ANS: B
The source of infection should be removed first. All of the other answers are possible interventions depending on the client's symptoms and vital signs, but removing the tampon is the priority.
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