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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. “Call your surgeon if you have any questions at home.”

This instruction is important as it encourages the patient to seek help and clarification if they have any concerns or questions about their postoperative care at home. However, while communication with the surgeon is essential, it is not as immediately critical as ensuring proper hand hygiene when dealing with wound care and drain management.

B. ”Eat a diet high in protein, iron, zinc, and vitamin C.”

Nutritional advice is crucial for postoperative recovery, as a balanced diet high in protein, iron, zinc, and vitamin C can promote wound healing and overall recovery. However, while important for long-term recovery and healing, dietary recommendations do not directly address the immediate risk of infection or complications associated with wound care and drain management.

C. “Wash your hands before touching the drain or dressing."

This instruction is the most important in this context because proper hand hygiene is crucial for preventing infections during wound care and drain management. Clean hands significantly reduce the risk of introducing harmful bacteria or contaminants to the surgical site, which can lead to infections and other complications. Ensuring that the patient washes their hands before touching the drain or dressing is a fundamental measure for promoting wound healing and preventing postoperative complications.

D. “Be sure you keep all your postoperative appointments.”

Keeping postoperative appointments is important for ongoing assessment, monitoring, and follow-up care. However, while essential for overall recovery and management of postoperative issues, it is not as immediate or directly related to the patient's ability to manage their dressing and drain at home.

A. Increased pulse rate B. Decreased blood pressure C. Skeletal muscle weakness D. Warm and pink skin E. Distended neck veins

Correct Answer is ["E"]

Explanation

A. Increased pulse rate:

This is a common manifestation of fluid overload. Excess fluid volume can lead to an increase in cardiac output, causing the heart to pump faster and resulting in an increased pulse rate.

B. Decreased blood pressure:

Fluid overload typically leads to increased blood volume, which can initially cause an increase in blood pressure. However, as fluid overload progresses, it can lead to fluid redistribution, venous congestion, and decreased systemic vascular resistance, ultimately resulting in decreased blood pressure.

C. Skeletal muscle weakness:

Skeletal muscle weakness is not a direct manifestation of fluid overload. It is more commonly associated with electrolyte imbalances, such as hypokalemia or hypomagnesemia, which can occur as a consequence of fluid shifts but are not specific to fluid overload itself.

D. Warm and pink skin:

Warm and pink skin is not typically associated with fluid overload. Instead, it is more indicative of adequate tissue perfusion and oxygenation. In fluid overload, skin changes may include edema, cool and clammy skin due to venous congestion, or signs of skin breakdown in areas of pressure.

E. Distended neck veins:

Distended neck veins, specifically jugular venous distention (JVD), are commonly seen in patients with fluid overload, especially if there is right-sided heart failure or increased central venous pressure. JVD is a result of increased venous return to the heart due to fluid accumulation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?

Correct Answer is C

Explanation

A nurse assesses a patient who is admitted for treatment of fluid overload. Which manifestations does the nurse expect to find? (Select all that apply.)

Correct Answer is ["E"]

Explanation

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