(Select all that apply): A nurse is providing care to a client with measles. What are the appropriate nursing interventions to manage this client? Select all that apply:
Administer antiviral medications.
Isolate the client in a private room with negative pressure ventilation.
Wear an N95 respirator mask when entering the client's room.
Monitor vital signs, especially temperature, pulse, and oxygen saturation.
Provide oral care to the client with Koplik spots or oral ulcers.
Correct Answer : C,D,E
Choice A rationale:
Antiviral medications are not typically used to treat uncomplicated cases of measles. Supportive care is the mainstay of treatment.
Choice B rationale:
Isolating the client in a private room with negative pressure ventilation is appropriate to prevent the spread of airborne infections like tuberculosis but is not a standard precaution for measles.
Choice C rationale:
Wearing an N95 respirator mask when entering the client's room is essential because measles is highly contagious and transmitted through the respiratory route.
Choice D rationale:
Monitoring vital signs, especially temperature, pulse, and oxygen saturation, is crucial to assess for any signs of complications and to monitor the client's overall condition.
Choice E rationale:
Providing oral care to the client with Koplik spots or oral ulcers is essential for maintaining oral hygiene and preventing secondary infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Encouraging the client to avoid exposure to sunlight is not a preventive measure for measles. Measles is a viral infection transmitted through respiratory droplets, not sunlight exposure. Sunlight exposure is important for the synthesis of vitamin D and has no direct relation to measles prevention.
Choice B rationale:
Advising the client to avoid contact with people who have a common cold is not a preventive measure for measles. While respiratory infections might have similar symptoms to measles, the viruses causing them are different, and avoiding people with a common cold would not protect against measles.
Choice C rationale:
Suggesting the client receive the live attenuated measles vaccine as part of the MMR combination is the correct preventive measure for measles. The MMR vaccine contains live but weakened forms of measles, mumps, and rubella viruses. It provides immunity against these diseases and is highly effective in preventing measles infection.
Choice D rationale:
Recommending taking antibiotics prophylactically is not appropriate for measles prevention. Measles is a viral infection, and antibiotics are only effective against bacterial infections, not viral ones. Prophylactic use of antibiotics can lead to antibiotic resistance and is not indicated for preventing measles.
Correct Answer is C
Explanation
Measles is transmitted through respiratory droplets and person-to-person contact.
Choice A rationale:
Measles is not transmitted through contaminated water sources. It is a highly contagious viral infection that primarily spreads through respiratory droplets when an infected person coughs or sneezes.
Choice B rationale:
Measles is not transmitted through contact with infected animals. It is a human-specific virus and does not infect animals.
Choice C rationale:
This is the correct choice. Measles is primarily transmitted through respiratory droplets when an infected person coughs or sneezes. It can also spread through direct contact with respiratory secretions or airborne particles.
Choice D rationale:
Measles is not transmitted through exposure to contaminated food. The virus is not foodborne, and the main mode of transmission is person-to-person through respiratory droplets.
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