A client is brought to the clinic with symptoms of measles. Which precaution should the nurse implement to prevent transmission to others?
Standard precautions.
Droplet precautions.
Contact precautions.
Airborne precautions.
The Correct Answer is D
The correct answer is choice d. Airborne precautions.
Choice A rationale:
Standard precautions are the basic level of infection control that should be used in the care of all patients all of the time. These precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources. However, they are not sufficient to prevent the transmission of measles, which is an airborne virus.
Choice B rationale:
Droplet precautions are used for diseases that are transmitted by large droplets that are expelled into the air and travel 3 to 6 feet from the patient. Measles is not primarily transmitted by large droplets and therefore, droplet precautions are not the most effective measure for preventing measles transmission.
Choice C rationale:
Contact precautions are used for infections, diseases, or germs that are spread by touching the patient or items in the patient’s room. Measles is highly contagious and can be spread through the air by breathing, coughing, or sneezing, so contact precautions alone would not prevent the spread of measles.
Choice D rationale:
Airborne precautions are required for diseases that are transmitted by smaller droplets, which remain in the air for long periods of time and can be spread over long distances when the infected person breathes, coughs, or sneezes. Measles is known to be highly contagious and can remain airborne for up to two hours in an airspace after the infected person leaves an area. Therefore, airborne precautions, which include the use of a high-efficiency particulate air (HEPA) filter and special respiratory protection, are necessary to prevent the spread of measles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale:
Antiviral medications are not typically used to treat uncomplicated cases of measles. Supportive care is the mainstay of treatment.
Choice B rationale:
Isolating the client in a private room with negative pressure ventilation is appropriate to prevent the spread of airborne infections like tuberculosis but is not a standard precaution for measles.
Choice C rationale:
Wearing an N95 respirator mask when entering the client's room is essential because measles is highly contagious and transmitted through the respiratory route.
Choice D rationale:
Monitoring vital signs, especially temperature, pulse, and oxygen saturation, is crucial to assess for any signs of complications and to monitor the client's overall condition.
Choice E rationale:
Providing oral care to the client with Koplik spots or oral ulcers is essential for maintaining oral hygiene and preventing secondary infections.
Correct Answer is C
Explanation
Choice A rationale:
Nucleoprotein (N) and phosphoprotein (P) are not responsible for viral entry and fusion in measles infection. These proteins are involved in viral replication and assembly, not the initial entry into host cells.
Choice B rationale:
Matrix protein (M) and large protein (L) are not responsible for viral entry and fusion in measles infection. The matrix protein plays a role in the assembly and structure of the virus, while the large protein is involved in viral replication and transcription.
Choice C rationale:
Fusion protein (F) and hemagglutinin protein (H) are the primary proteins responsible for viral entry and fusion in measles infection. The hemagglutinin protein allows the virus to bind to specific receptors on host cells, while the fusion protein facilitates the fusion of the viral envelope with the host cell membrane, allowing the virus to enter the cell.
Choice D rationale:
Nucleoprotein (N) and matrix protein (M) are not directly involved in viral entry and fusion. Nucleoprotein plays a role in protecting the viral RNA, and the matrix protein is involved in viral assembly and budding.
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