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A nurse is admitting a client who has rubella.
Which of the following actions should the nurse plan to take?

A.

Instruct the client's loved ones that the client should not have fresh flowers in their room.

B.

Wear a surgical mask when within 0.9 m (3 feet) of the client.

C.

Place the client in a room with negative-airflow pressure.

D.

Instruct the client that visitors will not be allowed while they are in isolation.

Answer and Explanation

The Correct Answer is B

 

The correct answer is choice B: Wear a surgical mask when within 0.9 m (3 feet) of the client.

 

Choice A rationale:

 Fresh flowers are generally discouraged in hospital settings for clients with compromised immune systems due to the risk of infection from soil or water, which can harbor harmful microorganisms. However, this is not specifically related to rubella, which is an airborne virus.

 

Choice B rationale:

 Rubella is transmitted through airborne droplets when an infected person coughs or sneezes. Wearing a surgical mask when close to the client can help prevent the spread of the virus. This is especially important to protect individuals who are pregnant or may become pregnant, as rubella can cause serious birth defects.

 

Choice C rationale:

 Negative-airflow pressure rooms are used for clients with airborne infections, such as tuberculosis. While rubella is also airborne, the current guidelines do not require a negative pressure room for its management.

 

Choice D rationale:

 While limiting visitors can help control the spread of infection, it is not the primary action to take for a client with rubella. The focus should be on preventing the spread through droplet transmission, which is addressed by wearing a mask and practicing good hand hygiene.


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Related Questions

Correct Answer is A

Explanation

Correct Answer is ["A","D"]

Explanation

Hypostatic Pneumonia Hypostatic pneumonia is a type of pneumonia that occurs when fluid or secretions settle in the lower lobes of the lungs, typically due to a lack of movement or staying in one position for too long. In this case, the client has paraplegia, which is a form of significant immobility. This condition prevents the client from effectively clearing their airway and results in decreased lung expansion.

Analysis of Evidence The clinical findings on Day 2 clearly indicate a progression toward an infectious respiratory process caused by this immobility:

  • Respiratory Status: The oxygen saturation has dropped from 95% to 89%, and the respiratory rate has increased from 20/min to 24/min (tachypnea).

  • Symptoms: The client has transitioned from a simple cough to a productive cough and is now experiencing confusion, which is a common sign of hypoxia in clinical settings.

  • Infection Markers: The client's temperature has risen to 38.4°C (101.1°F), and the WBC count is elevated at 12,500/mm³, indicating a systemic inflammatory response or infection.

  • Tachycardia: The heart rate has increased to 105/min, which is a compensatory mechanism for decreased oxygenation and the presence of a fever.

While the client's Hgb is slightly low (11.0 g/dL), it does not explain the acute onset of fever, confusion, and productive cough. Furthermore, there are no signs of fluid volume overload (such as edema or high BP) or calorie deficiency that would trigger these specific respiratory and febrile symptoms.

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