A nurse is admitting a client who has rubella. Which of the following actions should the nurse plan to take?

Instruct the client's loved ones that the client should not have fresh flowers in their room.

Wear a surgical mask when within 0.9 m (3 feet) of the client.

Place the client in a room with negative-airflow pressure.

Instruct the client that visitors will not be allowed while they are in isolation.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Instructing the client's loved ones that the client should not have fresh flowers in their room (Choice A) is not a necessary action for rubella isolation. Rubella is transmitted through respiratory droplets, and the prohibition of fresh flowers is not a relevant precaution.

Choice B rationale:

Wearing a surgical mask when within 0.9 m (3 feet) of the client (Choice B) is the correct action. Rubella is an airborne disease, and wearing a surgical mask helps prevent the spread of infectious respiratory droplets to the nurse and other individuals.

Choice C rationale:

Placing the client in a room with negative-airflow pressure (Choice C) is not specifically indicated for rubella isolation. Negative-airflow pressure rooms are typically used for diseases that require strict airborne precautions, such as tuberculosis.

Choice D rationale:

Instructing the client that visitors will not be allowed while they are in isolation (Choice D) is not entirely accurate for rubella isolation. While isolation precautions are necessary, visitors can enter the room if they are properly protected, including wearing masks and following infection control protocols.

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Correct Answer is B

Explanation

Choice A rationale:

Providing a cup of hot chocolate prior to bedtime is not a suitable intervention for a client reporting difficulty sleeping. Hot chocolate contains caffeine, which can act as a stimulant and interfere with sleep. Caffeine is known to disrupt sleep patterns and should be avoided close to bedtime.

Choice B rationale:

Scheduling exercise activities at least 3 hours before bedtime is the correct intervention for a client experiencing difficulty sleeping. Regular exercise promotes better sleep quality by helping to regulate the sleep-wake cycle and improve sleep duration. However, exercising too close to bedtime can have a stimulating effect, making it harder for the client to fall asleep. By scheduling exercise activities earlier in the day, the client's body will have sufficient time to wind down before bedtime, leading to improved sleep.

Choice C rationale:

Keeping soft music playing at bedtime and throughout the night might not be effective for everyone. While soft music can create a calming environment and help some individuals relax, it may not address the underlying causes of the client's difficulty sleeping. Additionally, some people might find background noise disruptive to their sleep. Therefore, this option might not be as effective as adjusting the timing of exercise.

Choice D rationale:

Scheduling mealtime 2 hours before bedtime is generally a good practice, but it might not directly address the client's reported difficulty sleeping. Consuming heavy or spicy meals close to bedtime can cause discomfort and indigestion, which might interfere with sleep. However, adjusting mealtime alone might not be sufficient to resolve the client's sleep issues, especially if other factors are contributing to their insomnia.

A. Metabolic acidosis. B. Respiratory acidosis. C. Metabolic alkalosis. D. Respiratory alkalosis.

Correct Answer is C

Explanation

Choice A rationale:

Metabolic acidosis is not the correct acid-base imbalance for the given ABG results. Metabolic acidosis is characterized by a low pH (acidic), low bicarbonate (HCO3) levels, and a compensatory decrease in the PaCO2. In the provided ABG results, the pH is elevated, and both the PaCO2 and HCO3 levels are within normal ranges.

Choice B rationale:

Respiratory acidosis is also not the correct acid-base imbalance for the given ABG results. Respiratory acidosis occurs when there is an elevation in PaCO2 due to inadequate ventilation, leading to an acidic pH. In the provided ABG results, the pH is elevated, and the PaCO2 level is within normal range.

Choice C rationale:

Metabolic alkalosis is the correct acid-base imbalance for the given ABG results. Metabolic alkalosis is characterized by an elevated pH, elevated bicarbonate (HCO3) levels, and a compensatory increase in PaCO2. In this case, the pH is higher than the normal range, the HCO3 level is elevated, and the PaCO2 is also slightly increased as the body attempts to compensate.

Choice D rationale:

Respiratory alkalosis is not the correct answer based on the provided ABG results. Respiratory alkalosis is marked by an elevated pH and a decrease in PaCO2 due to excessive ventilation. In the given ABG results, the pH is elevated, but the PaCO2 is not decreased; it's within the normal range.

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A nurse is admitting a client who has rubella. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who reports having difficulty sleeping. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is reviewing the ABG results for a client. The client's results are pH 7.47, PaCO2 30 mm Hg, HCO3 25 mEq/L, and SaO2 90%. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

Correct Answer is C

Explanation

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