A nurse is caring for a client.
Which of the following actions should the nurse take? (Select all that apply.)
Wear a mask when caring for the client.
Place the client in private room.
Encourage the client to increase fluid intake.
Place the client on contact precautions.
Prepare to administer an antibiotic to the client.
Correct Answer : A,B,C
A. Wear a mask when caring for the client: This is an important action to prevent the spread of influenza, which is transmitted via respiratory droplets. Wearing a mask helps protect both the healthcare provider and other patients from potential exposure to the virus, especially in the early stages of the disease when the client is most contagious.
B. Place the client in a private room: This action is recommended to minimize the risk of transmitting the influenza virus to other patients. Isolating the client in a private room can help control the spread of infection, making it a necessary measure in this situation.
C. Encourage the client to increase fluid intake: Adequate hydration is essential for clients with influenza to help alleviate fever and maintain overall health. Increasing fluid intake supports the immune system and helps prevent complications such as dehydration, so encouraging the client to drink more fluids is appropriate.
D. Place the client on contact precautions: While contact precautions are essential for preventing the spread of infections transmitted by direct contact, they are not specifically necessary for influenza, which is primarily airborne and droplet transmitted. Standard precautions, including droplet precautions, are sufficient for managing a client with influenza.
E. Prepare to administer an antibiotic to the client: This action is not appropriate because influenza is a viral infection, and antibiotics are ineffective against viruses. Treatment for influenza typically involves antiviral medications if indicated, supportive care, and symptom management rather than antibiotics. Therefore, this option should not be included in the actions the nurse takes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Your body will slowly develop an ability to smell through your stoma." The olfactory system relies on air passing through the nasal passages to detect scents. After a total laryngectomy, the airway is rerouted through a stoma, bypassing the nose entirely. The body does not develop an alternative way to smell through the stoma, making this statement inaccurate.
B. "Breathing through a stoma has altered your sense of smell." A total laryngectomy permanently separates the respiratory and digestive tracts, preventing air from passing through the nose, which is necessary for olfaction. As a result, clients often experience anosmia (loss of smell). This response accurately explains the reason behind the alteration in the client’s sense of smell.
C. "Your sense of smell will gradually return after several months." Unlike temporary post-surgical changes, the loss of smell after a total laryngectomy is typically permanent unless the client learns to use techniques such as the "polite yawning" method (nasal airflow-inducing maneuver) to regain some olfactory function. It does not naturally return over time.
D. "As your appetite returns, your sense of smell will also return." Appetite and sense of smell are closely linked, but appetite improvement does not restore olfaction after a laryngectomy. Since air no longer flows through the nasal passages, the ability to detect smells is significantly impaired or lost.
Correct Answer is ["A","B","C"]
Explanation
A. Wear a mask when caring for the client: This is an important action to prevent the spread of influenza, which is transmitted via respiratory droplets. Wearing a mask helps protect both the healthcare provider and other patients from potential exposure to the virus, especially in the early stages of the disease when the client is most contagious.
B. Place the client in a private room: This action is recommended to minimize the risk of transmitting the influenza virus to other patients. Isolating the client in a private room can help control the spread of infection, making it a necessary measure in this situation.
C. Encourage the client to increase fluid intake: Adequate hydration is essential for clients with influenza to help alleviate fever and maintain overall health. Increasing fluid intake supports the immune system and helps prevent complications such as dehydration, so encouraging the client to drink more fluids is appropriate.
D. Place the client on contact precautions: While contact precautions are essential for preventing the spread of infections transmitted by direct contact, they are not specifically necessary for influenza, which is primarily airborne and droplet transmitted. Standard precautions, including droplet precautions, are sufficient for managing a client with influenza.
E. Prepare to administer an antibiotic to the client: This action is not appropriate because influenza is a viral infection, and antibiotics are ineffective against viruses. Treatment for influenza typically involves antiviral medications if indicated, supportive care, and symptom management rather than antibiotics. Therefore, this option should not be included in the actions the nurse takes.
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