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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason:

Positive Trousseau's sign is incorrect. Trousseau's sign is associated more with calcium imbalances, particularly hypocalcemia, and is assessed by inflating a blood pressure cuff on the arm to induce carpal spasm. It's not a specific indicator of metabolic acidosis related to high glucose levels in diabetes mellitus.

Choice B Reason:

Dizziness upon standing is incorrect. Dizziness upon standing, also known as orthostatic hypotension, is more commonly associated with blood pressure changes upon position changes. While it can occur in various conditions, it's not a specific indicator of metabolic acidosis in this context.

Choice C Reason:

Tingling of the fingers is incorrect. Tingling sensations, known as paresthesia, can occur due to various reasons, including nerve damage related to chronic high blood sugar levels in diabetes (diabetic neuropathy). However, it's not a direct and specific indicator of metabolic acidosis caused by high glucose levels in diabetes mellitus.

Choice D Reason:

Increased respiratory rate is correct. Metabolic acidosis in a diabetic individual can trigger compensatory mechanisms, such as increased respiratory rate (Kussmaul respirations), as the body tries to eliminate excess acids through respiration to help regulate the acid-base balance. This increased respiratory rate is an attempt to blow off carbon dioxide (a potential acidic byproduct) and decrease the acidity in the blood.

A. "You will not become fatigued when you use assistive devices." B. "Plan to hire a home care aid to perform all of your ADLs." C. "Install grab bars in your shower to assist with your balance." D. "Place a towel in the shower to prevent slipping

Correct Answer is C

Explanation

Choice A Reason:

"You will not become fatigued when you use assistive devices. “This statement might provide an unrealistic expectation. While assistive devices can help, they might still require physical effort and could potentially cause fatigue, especially during initial use or extended periods.

Choice B Reason:

"Plan to hire a home care aid to perform all of your ADLs." This statement is not appropriate.

While home care assistance can be beneficial, aiming to have someone perform all ADLs might limit the client's independence and ability to regain skills. The goal is often to support the client in performing ADLs independently whenever possible.

Choice C Reason:

"Install grab bars in your shower to assist with your balance." This statement is true. Installing grab bars in the shower can significantly enhance safety and stability during activities like showering, reducing the risk of falls for someone who might experience balance or mobility challenges following a CVA.

Choice D Reason:

"Place a towel in the shower to prevent slipping." This statement is inappropriate. While placing a towel might offer some traction, it might not provide sufficient stability or support, especially for someone with balance issues post-CVA. Grab bars offer more reliable support to prevent falls in the shower.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dl. (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?

Correct Answer is D

Explanation

A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?

Correct Answer is C

Explanation

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