A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?
Administer aspirin if the client develops a fever.
Initiate contact precautions for the client.
Assign the client to a negative-pressure airflow room.
Have visitors remain at least 0.91 m (3 feet. away from the client.
The Correct Answer is C
The correct answer is choice c. Assign the client to a negative-pressure airflow room.
Choice A rationale:
Administering aspirin to a client with varicella zoster is not recommended due to the risk of Reye’s syndrome, a serious condition that can cause swelling in the liver and brain.
Choice B rationale:
While contact precautions are important, varicella zoster also requires airborne precautions due to its highly contagious nature. This means that simply initiating contact precautions is not sufficient.
Choice C rationale:
Assigning the client to a negative-pressure airflow room is crucial because it helps contain the airborne virus and prevents it from spreading to other areas of the hospital.
Choice D rationale:
Having visitors remain at least 0.91 m (3 feet) away from the client is a good practice, but it is not sufficient on its own to prevent the spread of the virus. Airborne precautions, including a negative-pressure room, are necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Patterned-paced breathing might help with pain management, but it's not specific to changing positions.
B. Correct. Splinting the incision with a pillow provides support and reduces strain when changing positions, minimizing discomfort.
C. Counterpressure to the back might be helpful during contractions, but it's not specific to postoperative pain with position changes.
D. While reducing position changes might be initially suggested, it's important for postoperative clients to move to prevent complications like deep vein thrombosis. Providing strategies to manage pain during position changes is more appropriate.
Correct Answer is B
Explanation
A. Incorrect. No sounds heard after listening for 3 to 5 minutes would be considered absent bowel sounds.
B. Correct. Hyperactive bowel sounds are louder and more frequent than normal and can indicate increased bowel motility. They can also be present in early bowel obstructions due to increased peristalsis.
C. Incorrect. Soft sounds at a rate of 1/min are within the range of normal bowel sounds.
D. Incorrect. Decreased motility would result in hypoactive bowel sounds, not hyperactive.
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