A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?
Have the client wear a surgical mask during transport.
Wear an N95 mask while providing care to the client.
Administer an influenza immunization to the client.
Place the client in a negative airflow room.
Correct Answer : A
a. Have the client wear a surgical mask during transport. This is the appropriate intervention to prevent the spread of the influenza virus when the client needs to be transported within the healthcare facility. Influenza is primarily spread through respiratory droplets, so wearing a surgical mask helps to contain these droplets.
b. Wear an N95 mask while providing care to the client. An N95 mask is generally not required for influenza. Standard precautions, including wearing a surgical mask when within close proximity to the client, are usually sufficient.
c. Administer an influenza immunization to the client. It is not appropriate to administer the influenza vaccine to a client who is already infected with the influenza virus.
d. Place the client in a negative airflow room. Negative airflow rooms are typically reserved for airborne diseases such as tuberculosis. Influenza, which spreads via droplets, does not require this level of isolation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Informing the client of the adverse effect of diarrhea is less common with clonidine use, especially in comparison to other side effects like dry mouth or skin irritation.
Choice B Reason:
Monitoring for weight loss isn't a primary concern specifically associated with transdermal clonidine use.
Choice C Reason:
Advise the client about increased dry mouth. Dry mouth is a common adverse effect of clonidine, including the transdermal form. Patients should be informed about this so they can manage it effectively, for example, by drinking plenty of water or using sugar-free gum or candy to stimulate saliva production.
Choice D Reason:
Hypopigmentation is not a commonly reported issue with transdermal clonidine patches. However, local skin irritation or rash can occur at the site of the patch.
Correct Answer is A
Explanation
Elevate the head of the client's bed for 1 hr. after the feeding is appropriate. This action helps minimize the risk of aspiration. Elevating the head of the bed (typically at least 30 to 45 degrees) can reduce the chance of reflux and aspiration of the feeding solution into the lungs. This position should ideally be maintained for about 1 hour after the feeding to aid digestion and reduce the risk of complications.
Choice B Reason:
Administering the feeding solution at a cold temperature is inappropriate. Feeding solutions are generally administered at room temperature or slightly warmed to prevent discomfort and minimize the risk of altering the client's core body temperature. Cold temperatures can cause discomfort or cramping and might affect the absorption of the nutrients. Therefore, administering the feeding solution at a cold temperature is not recommended.
Choice C Reason:
Rotating the jejunostomy tube once per day is inappropriate. Rotating the jejunostomy tube is not typically part of routine care. Tube rotation can cause discomfort, irritation, and potential injury to the gastrointestinal tract. Tubes should be secured properly to prevent movement but not rotated unless specifically instructed by a healthcare provider for a particular reason, such as checking for proper tube placement.
Choice D Reason:
Flushing the tube with 90 ml of sterile water before and after the feeding is inappropriate.
Flushing the tube with sterile water before and after the feeding helps ensure the patency of the tube and prevents clogging. It's a standard procedure to clear the tube and maintain its function.
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