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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Selecting a site at least 5 cm (2 in) away from the umbilicus is essential because the tissue around the navel is often tougher and has altered vascularity, which can lead to inconsistent medication absorption.
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Choice B rationale: Air bubbles in prefilled syringes, such as those used for enoxaparin, should not be expelled. The air bubble is designed to be injected last to seal the medication within the subcutaneous tissue and prevent leakage.
Choice C rationale: Aspiration is no longer recommended for subcutaneous injections. There are no large blood vessels in the subcutaneous layer, and aspiration increases the risk of tissue trauma, hematoma formation, and client discomfort.
Choice D rationale: Subcutaneous injections should be administered at a 45° to 90° angle, depending on the amount of subcutaneous fat available. A 15° angle is used specifically for intradermal injections, such as TB skin tests.
Correct Answer is C
Explanation
The correct answer is choiceC. “I’ll compare the sensations I feel when I tense my muscles to what I feel when I relax them.”
Choice A rationale:While breathing normally is important during relaxation techniques, progressive muscle relaxation specifically focuses on tensing and relaxing muscle groups to recognize the difference in sensations.
Choice B rationale:Imagining a peaceful setting is more related to guided imagery or visualization techniques, not progressive muscle relaxation.
Choice C rationale:This is correct because progressive muscle relaxation involves tensing and then relaxing muscle groups to help the individual recognize the difference between tension and relaxation.
Choice D rationale:Using a series of stretches is not a part of progressive muscle relaxation; it is more related to stretching exercises or yoga.
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