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 D
Explanation
A. While monitoring oxygen saturation is important, ensuring an open airway takes priority.
B. Administering oxygen is important, but ensuring an open airway is the initial priority.
C. Checking the pulse rate is important, but ensuring an open airway is the initial priority.
D. Correct. Establishing a patent airway is the most critical action for a client with compromised breathing and cyanosis.
Correct Answer is D
Explanation
Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening skin reaction that can occur as a rare but serious side effect of allopurinol. The initial symptom often presents as a skin rash, which can progress rapidly and involve other mucous membranes such as the mouth and eyes. Fever is commonly associated with SJS.
Diplopia (double vision) is not a typical symptom of SJS. It refers to seeing two images instead of one and can be caused by various factors unrelated to allopurinol or SJS.
Tinnitus with ear pain is not a characteristic symptom of SJS. It usually relates to issues with the auditory system, such as damage to the inner ear or other underlying conditions.
Hyperreflexia (exaggerated reflexes) is not directly associated with SJS. It typically refers to an abnormal increase in the body's reflex responses and can be caused by conditions affecting the central nervous system or spinal cord.
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