A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection?

Administer metronidazole.

Don protective eyewear before entering the room.

Place the client in a negative airflow room.

Wear a mask when working within 3 feet of the client.

Answer and Explanation

The Correct Answer is D

A. Administer metronidazole:

Metronidazole is an antibiotic medication used to treat bacterial infections, particularly those caused by anaerobic bacteria and certain parasites. It is not effective against viral infections like influenza. Administering metronidazole would not prevent the spread of influenza.

B. Don protective eyewear before entering the room:

Protective eyewear is typically worn when there is a risk of exposure to bodily fluids or other potentially infectious materials that could splash or splatter into the eyes. While protective eyewear is an important infection control measure in certain situations, it is not specifically indicated for preventing the spread of influenza, which primarily spreads through respiratory droplets.

C. Place the client in a negative airflow room:

Negative airflow rooms are designed to prevent airborne transmission of infectious agents by maintaining negative air pressure, which prevents contaminated air from flowing out of the room and into adjacent areas. While negative airflow rooms may be used for certain infectious diseases, such as tuberculosis, they are not typically indicated for influenza, which primarily spreads through respiratory droplets. Moreover, negative airflow rooms are often limited in availability and may not be necessary for every client with influenza.

D. Wear a mask when working within 3 feet of the client.

Influenza is primarily spread through respiratory droplets when an infected person coughs, sneezes, or talks. Wearing a mask when working within close proximity (within 3 feet) of the client helps prevent the nurse from inhaling respiratory droplets containing the influenza virus, reducing the risk of transmission. Masks act as a barrier that helps trap respiratory secretions and prevent them from reaching the nurse's mouth and nose.

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Correct Answer is B

Explanation

A. The client leans to the left side while sitting: While leaning to one side may indicate weakness or impaired balance, it is not as immediately concerning as the risk of aspiration. Addressing issues related to positioning and balance is important but may not pose an immediate threat to the client's safety.

B. The client coughs frequently while eating.

Coughing frequently while eating can indicate a risk of aspiration, which is a serious concern in stroke patients with left-sided weakness. Aspiration can lead to pneumonia and other respiratory complications. Therefore, it is crucial for the nurse to address this finding promptly to prevent potential respiratory compromise.

C. The client is consuming 25% of their meals: Poor oral intake and difficulty eating are concerning but do not pose an immediate threat to the client's safety compared to the risk of aspiration. However, addressing inadequate nutrition and hydration is essential for the client's overall health and recovery.

D. The client's blood pressure is 142/94 mm Hg: While monitoring blood pressure is important, especially in stroke patients who may have hypertension, the blood pressure reading provided does not indicate a hypertensive crisis or immediate risk to the client's safety. Therefore, it is not the priority finding compared to the risk of aspiration.

A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference. B. Reposition the client supine and recheck her BP. C. Recheck the client's BP in her other arm for comparison. D. Request that another nurse check the client's BP in 30 min.

Correct Answer is C

Explanation

A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:

While using an appropriately sized cuff is crucial for accurate blood pressure measurement, the width of the cuff should be about 40% of the circumference of the upper arm, not 50%. However, adjusting the cuff size is not the most immediate action to take when faced with an elevated blood pressure reading.

B. Reposition the client supine and recheck her BP:

Repositioning the client supine is not necessary for routine blood pressure measurement in a sitting position. Moreover, repositioning the client may not significantly affect the blood pressure reading, especially if the initial reading was obtained correctly.

C. Recheck the client's BP in her other arm for comparison.

When obtaining a blood pressure reading, it's important to confirm the accuracy of the measurement, especially if the reading is elevated. Checking the blood pressure in the other arm allows for comparison and helps identify any significant differences between the arms, which could indicate arterial abnormalities or other issues. This step ensures accuracy and helps in making appropriate clinical decisions.

D. Request that another nurse check the client's BP in 30 min:

Waiting 30 minutes to recheck the blood pressure is not the most appropriate action when faced with an elevated reading. Prompt reevaluation and comparison of blood pressure readings are essential for accurate assessment and timely intervention, especially if the initial reading indicates hypertension.

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