A nurse in a clinic is caring for a middle-aged patient who states, “The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening.
What does that involve?” Which of the following responses should the nurse make?

Choice A rationale: Implementing airborne precautions is not necessary in this case. The client’s symptoms and the progression of their condition suggest a severe respiratory infection, possibly pneumonia, but there is no indication that the infection is airborne.

Airborne precautions are typically reserved for diseases that are spread through tiny droplets in the air, such as tuberculosis, measles, or chickenpox.

Choice B rationale: The client’s worsening respiratory distress, evidenced by increased shortness of breath, use of accessory muscles for breathing, decreased oxygen saturation, and changes in sputum, indicate that the client may require intubation and mechanical ventilation. This would ensure that the client’s airway remains open and that they receive adequate oxygen.

Choice C rationale: The client has a history of well-managed diabetes mellitus. Given the stress of the illness and the initiation of corticosteroid therapy (which can raise blood glucose levels), it would be important to monitor the client’s blood glucose levels frequently.

Choice D rationale: The client has been prescribed Levofloxacin, an antibiotic, which should be administered as prescribed. Given the client’s symptoms and the progression of their condition, it is likely that they have a bacterial infection. Antibiotics are critical for treating bacterial infections.

Choice E rationale: Ensuring strict hand hygiene before and after client contact is a standard precaution in all healthcare settings to prevent the spread of infection.

Choice F rationale: Increasing fluid intake can help thin out the sputum, making it easier for the client to cough it up. This can help improve the client’s respiratory function.

Choice G rationale: There is no current indication for a chest tube insertion. While the client’s chest X-ray shows extensive consolidation and possible pleural effusion, the notes do not indicate that the effusion is large enough to require drainage at this time. A chest tube would be considered if the effusion was large and causing significant respiratory distress, which is not clearly the case here.

Choice A rationale

Biofeedback is a mind-body technique that helps individuals gain control over bodily processes that are normally involuntary. It is not contraindicated for a client with herpes zoster.

Choice B rationale

Aloe is a plant-based product often used for its soothing and healing properties. It is not contraindicated for a client with herpes zoster.

Choice C rationale

Feverfew is a medicinal herb often used for its anti-inflammatory properties. It is not contraindicated for a client with herpes zoster.

Choice D rationale

Acupuncture involves the insertion of thin needles into specific points on the body. It is contraindicated for a client with herpes zoster because it could potentially open a portal on the skin’s surface, increasing the risk of further infection.