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?
Assign the client to a negative pressure airflow room
Have visitors remain at least 0.91 m (3 feet) away from the client
Initiate contact precautions for the client
Administer aspirin if the client develops a fever
Correct Answer : A,C
Varicella zoster is highly contagious, and airborne precautions should be implemented. Assigning the client to a negative pressure airflow room helps prevent the spread of the virus to others by containing and filtering the air within the room.
In addition to airborne precautions, contact precautions should also be implemented. This includes using gloves and gowns when providing care to the client to minimize direct contact with infectious materials.
The other options listed are not appropriate interventions for a client with varicella zoster: While it is important to minimize close contact with an infectious client, varicella zoster is primarily transmitted through airborne droplets. Visitors should follow the appropriate precautions, such as wearing masks and adhering to hand hygiene, rather than just maintaining a certain distance.
Aspirin should not be given to clients with varicella zoster, especially children, due to the risk of developing Reye's syndrome. Reye's syndrome is a rare but serious condition that can cause swelling in the liver and brain. Acetaminophen (paracetamol) is typically recommended for managing fever in clients with varicella zoster.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
A.While it's important to document visitors and support persons, this information may not be considered crucial for the change-of-shift report unless it directly impacts the client's care or well-being.
B. The client received the prescribed antibiotic every 8 hours: This is important information, but it is typically documented in the medication administration record (MAR) and does not need to be included in the verbal report unless there were issues or changes related to the medication.
C. The client reports pain is reduced when positioned on his side: This is significant information as it informs the incoming nurse about the client's preferred position for pain management. It helps guide the nurse in providing comfort measures and appropriate positioning for the client. The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.
D. The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.
Correct Answer is A
Explanation
Understanding the client's current voiding pattern is essential in developing an effective bladder training program. By determining the client's pattern for voiding, the nurse can identify any irregularities, frequency, and specific times when the client is more likely to void. This information will serve as a baseline for developing an individualized bladder training program. Offering toileting opportunities every 1 to 2 hours is an appropriate intervention to ensure regular and scheduled voiding. However, before implementing this intervention, it is necessary to determine the client's current voiding pattern to identify any existing irregularities or potential areas of improvement.
Assisting the client with relaxation techniques can help promote effective voiding and reduce anxiety or stress related to the act of voiding. However, this intervention can be more effective once the nurse has assessed the client's voiding pattern and identified specific areas where relaxation techniques can be beneficial.
Discouraging intake of carbonated beverages is a valid intervention as carbonated beverages can irritate the bladder and contribute to increased frequency and urgency of urination. However, this intervention can be implemented as part of a comprehensive bladder training program after the nurse has assessed the client's current voiding pattern and developed an individualized plan.
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