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.

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

Place the client in a negative airflow room.

Answer and Explanation

The Correct Answer is C

C. Wearing a mask when working within close proximity to the client helps prevent the transmission of respiratory droplets containing the influenza virus. This is especially important when providing direct care to the client, such as during assessments or procedures.
A. Metronidazole is an antibiotic used to treat bacterial infections, not viral infections like influenza. Administering metronidazole would not prevent the spread of influenza.
B. Protective eyewear is typically used to prevent exposure to bloodborne pathogens or other bodily fluids that could splash into the eyes. In the case of influenza, the primary mode of transmission is through respiratory droplets, so protective eyewear is not necessary for preventing its spread.
D. Negative airflow rooms are typically used for clients with airborne infections, such as tuberculosis, where there is a risk of droplet nuclei remaining suspended in the air for prolonged periods. Influenza is primarily spread through respiratory droplets and does not require negative airflow isolation.

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Correct Answer is B

Explanation

B. Ensuring the new ties are securely in place before removing the old ties prevents accidental displacement of the tracheostomy tube, which could lead to respiratory distress or other complications
A. Allowing space for three fingers under the ties would make the ties too loose, risking displacement of the tracheostomy tube. The correct practice is to allow space for one or two fingers to ensure the ties are snug enough to secure the tube without being too tight and causing discomfort or pressure injury.
C. Using a quick-release knot or Velcro ties is recommended because it allows for quick removal of the ties in case of an emergency, making it easier and faster to access the tracheostomy site if needed.
However, too loose knots can lead to dislodging of the tube.
D. Extending the client's neck while securing the ties is not recommended because it can cause discomfort and is not necessary for securing the tracheostomy ties. The client should be positioned comfortably with their neck in a neutral position to avoid unnecessary strain or discomfort.

A. Offer pain medication. B. Palpate the abdomen. C. Administer an antiemetic. D. Auscultate bowel sounds.

Correct Answer is D

Explanation

D. Auscultating bowel sounds is a non-invasive assessment that can provide important information about the functioning of the gastrointestinal system. It is typically done before palpation because palpation can alter bowel sounds and affect the accuracy of the assessment.
A. While pain relief is important, administering pain medication before a thorough assessment can mask symptoms and make diagnosis more difficult. Pain medication should be provided after an initial assessment and once a clearer understanding of the underlying issue is obtained.
B. Palpating the abdomen is a crucial part of the physical examination, especially when assessing abdominal pain. However, it should not be the first step. Before palpation, the nurse needs to gather more information through less invasive assessments to avoid causing additional discomfort or complications.
C. Administering an antiemetic can help alleviate nausea and vomiting, but similar to pain medication, it should not be done before a thorough assessment. The underlying cause of the symptoms needs to be identified first to ensure that the treatment provided is appropriate and does not obscure important diagnostic signs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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