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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
In the "background" portion of the SBAR communication tool, the nurse should include the client's present condition. This information provides the provider with context and a clear understanding of the client's current status. It helps the provider to have a baseline understanding before moving on to the assessment and recommendation stages of the communication. Including the client's present condition allows the provider to quickly grasp the urgency and severity of the situation, enabling them to make informed decisions regarding the client's care.
Choice B rationale:
Suggestions for the provider regarding client care are typically included in the "assessment" or "recommendation" portions of the SBAR communication tool, rather than the "background" portion. The "background" portion is focused on providing information about the current situation and the client's present condition, setting the stage for the rest of the communication.
Choice C rationale:
Physical findings are part of the assessment and observation of the client's current condition. While important, these findings are better suited for the "assessment" portion of the SBAR communication. The nurse should summarize the physical findings in the "assessment" section after providing the context in the "background" section.
Choice D rationale:
Previous treatments are also relevant information, but they belong in the "assessment" or "background" portions of the SBAR communication tool. The nurse should provide the provider with information about the client's current condition before discussing previous treatments, as the provider needs to know the current situation before considering the relevance of past interventions.
Correct Answer is D
Explanation
Choice A rationale:
Using a 5-mL syringe to flush the catheter is not the best choice. Central venous access devices typically require a larger syringe for flushing to prevent excessive pressure and potential damage to the catheter. A smaller syringe like the 5-mL syringe can create higher pressure, which could cause complications.
Choice B rationale:
Changing the site dressing and stabilization device every 24 hours is not the recommended practice. The dressing and stabilization device should be changed according to facility policy and as needed, but a rigid 24-hour schedule is not necessary and might increase the risk of infection due to unnecessary exposure.
Choice C rationale:
Expecting blood to appear in the catheter lumen after flushing is incorrect. Blood in the catheter lumen after flushing could indicate complications such as a dislodged catheter or other issues requiring immediate attention. The catheter should ideally remain patent without the presence of blood.
Choice D rationale:
This is the correct choice. Using chlorhexidine solution to clean the catheter is an evidence-based practice to prevent infection at the insertion site. Chlorhexidine has broad-spectrum antimicrobial properties and helps reduce the risk of catheter-related infections.
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