A frail, older adult home health patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?
Arrange for the patient to receive gamma globulin.
Assess frequently for herpes zoster.
Be aware of the patient's immunity to chickenpox.
Encourage the patient to have a pneumonia vaccine.
The Correct Answer is C
A. Arrange for the patient to receive gamma globulin.
Gamma globulin is a blood product that contains antibodies and is sometimes used for post-exposure prophylaxis in certain situations, such as for individuals who are immunocompromised or pregnant and have been exposed to varicella (chickenpox) or measles. However, for a frail, older adult who had chickenpox as a child and has been exposed to varicella again, arranging for gamma globulin may not be necessary if the patient is already immune to chickenpox.
B. Assess frequently for herpes zoster.
Herpes zoster (shingles) is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. While exposure to varicella can increase the risk of developing shingles in individuals who are susceptible, frequent assessment for herpes zoster is not necessary in this case if the patient is known to have had chickenpox in the past.
C. Be aware of the patient's immunity to chickenpox.
This option is the correct choice. Since the patient had chickenpox as a child, they likely have immunity to chickenpox. Being aware of this immunity helps the nurse understand that the patient may not develop chickenpox again even after exposure to varicella.
D. Encourage the patient to have a pneumonia vaccine.
Encouraging the patient to have a pneumonia vaccine is unrelated to the immediate concern of exposure to varicella. While pneumonia vaccines are important for older adults, especially those who are frail, the priority in this scenario is to determine the patient's immunity to chickenpox due to prior infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Increase the effectiveness of the skin graft:
Debridement can indeed increase the effectiveness of a skin graft by preparing a clean, viable wound bed for grafting. Removing dead tissue and debris helps the skin graft adhere to healthy tissue and promotes successful graft take. However, this is not the primary purpose of debridement.
B. Promote movement in the affected area:
While debridement can indirectly contribute to promoting movement by improving wound healing and reducing pain, the primary purpose of debridement is not to promote movement in the affected area.
C. Prevent infection and promote healing:
This statement accurately reflects the primary purpose of debridement. By removing nonviable tissue, debris, and foreign material from the wound, debridement helps prevent infection by reducing the bacterial load and creating an environment conducive to healing. It also promotes granulation tissue formation and wound contraction, which are essential for wound healing.
D. Promote suppuration of the wound:
Suppuration refers to the formation and discharge of pus from a wound, often indicating infection. Debridement aims to remove necrotic tissue and prevent infection, so promoting suppuration is not a desired outcome of debridement.
Correct Answer is A
Explanation
A. Stop the infusion of IV fluids:
This action may be appropriate if there are signs of infiltration or extravasation, where the IV fluid leaks into the surrounding tissue instead of entering the vein. Stopping the infusion can help prevent further tissue damage and assess the extent of the infiltration.
B. Apply cold compresses to the IV site:
Cold compresses can help reduce swelling and discomfort at the IV site. This action may be appropriate if there are signs of local inflammation or mild irritation at the insertion site.
C. Elevate the extremity on a pillow:
Elevating the extremity can help reduce swelling and promote venous return. This action is beneficial if there is edema or localized swelling above the IV site.
D. Flush the catheter with normal saline:
Flushing the catheter with normal saline is not typically the initial action in response to edema and tenderness above the IV site. Flushing is more commonly performed to ensure patency and proper functioning of the IV catheter.
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