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

The correct answer is choice B: Wear a surgical mask when within 0.9 m (3 feet) of the client.

Choice A rationale:

Fresh flowers are generally discouraged in hospital settings for clients with compromised immune systems due to the risk of infection from soil or water, which can harbor harmful microorganisms. However, this is not specifically related to rubella, which is an airborne virus.

Choice B rationale:

Rubella is transmitted through airborne droplets when an infected person coughs or sneezes. Wearing a surgical mask when close to the client can help prevent the spread of the virus. This is especially important to protect individuals who are pregnant or may become pregnant, as rubella can cause serious birth defects.

Choice C rationale:

Negative-airflow pressure rooms are used for clients with airborne infections, such as tuberculosis. While rubella is also airborne, the current guidelines do not require a negative pressure room for its management.

Choice D rationale:

While limiting visitors can help control the spread of infection, it is not the primary action to take for a client with rubella. The focus should be on preventing the spread through droplet transmission, which is addressed by wearing a mask and practicing good hand hygiene.

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Correct Answer is B

Explanation

The correct answer is choice B: Dyspnea.

Choice B rationale: Dyspnea, or difficulty breathing, is a potential indication of a recurrent pulmonary embolism and should be reported immediately. Early detection and intervention are crucial to prevent life-threatening complications.

Choice A rationale: Hypotension may be a concerning finding in postoperative clients, but it is not the priority for a client with a history of pulmonary embolism. Hypotension could be related to various factors like bleeding or anesthesia effects.

Choice C rationale: Dry cough may occur as a result of irritation or inflammation in the airway due to the surgical procedure or anesthesia. Although it should be monitored, it is not the highest priority in this situation.

Choice D rationale: Tachycardia can be a common postoperative finding due to pain, anxiety, or other factors. Although it should be monitored and addressed, it is not the most critical concern in this case. Dyspnea is more closely related to a possible pulmonary embolism and should be reported promptly.

A. Complete an incident report. B. Notify the client's provider. C. Document the fall in the client's medical record. D. Measure the client's vital signs.

Correct Answer is D

Explanation

The correct answer is D. The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.

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

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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