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 A
Explanation
Choice A Reason:
Passing of flatus is correct. Passing flatus (gas) is an encouraging sign that the digestive system is functioning and that gas is moving through the colostomy. This is a positive indicator of colostomy function.
Choice B Reason:
Stoma is pinkish-red. A pinkish-red stoma indicates good blood circulation to the area, which is vital for the health of the stoma tissue. A healthy-colored stoma is a positive sign.
Choice C Reason:
Tolerating a clear liquid diet. Tolerating a clear liquid diet might be an indicator of gastrointestinal function, but it might not specifically confirm the functionality of the colostomy itself.
D. Absent bowel sounds
Absent bowel sounds might be present immediately postoperatively due to the effects of anesthesia and abdominal surgery. However, bowel sounds aren't a direct indicator of colostomy function.
Correct Answer is D
Explanation
Choice A Reason:
"I can have clear liquids up to 3 hours before the procedure." This is incorrect. Clients are usually instructed to be NPO (nothing by mouth) for a certain period before the procedure, typically 6-8 hours, to reduce the risk of aspiration.
Choice B Reason:
"I can eat as soon as the procedure is completed." This is incorrect. Clients should not eat or drink until the gag reflex returns, which can take a few hours after the procedure.
Choice C Reason:
"I will receive an injection of radioactive material prior to having the procedure.” This is incorrect. An injection of radioactive material is not part of a bronchoscopy. This might be confused with a different diagnostic procedure, such as a PET scan.
Choice D Reason:
"I might have blood-tinged sputum after the procedure." This statement indicates an understanding of the teaching. It is common for clients to have a small amount of blood-tinged sputum following a bronchoscopy due to the irritation caused by the procedure.
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