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

The correct answer is Choice A.

Choice A rationale:

The client has influenza, which is a respiratory illness that can be transmitted through droplets when the infected person coughs, sneezes, or talks. The UAP is in close contact with the client while assisting them to sit up in bed to eat lunch. Therefore, it is necessary for the UAP to wear a face mask in addition to a gown and gloves to prevent the spread of the virus.This is in line with the Centers for Disease Control and Prevention (CDC) guidelines, which recommend that healthcare personnel wear a face mask when they are in the same room as a patient with suspected or confirmed influenza.

Choice B rationale:

A fitted respirator mask is not necessary in this situation.According to the Occupational Safety and Health Administration (OSHA), respirators are required for airborne diseases such as tuberculosis, but not for influenza, which is a droplet-transmitted disease. Therefore, reminding the UAP to apply a fitted respirator mask before entering the client’s room is not the most appropriate action.

Choice C rationale:

Assigning the UAP to provide care for another client and assuming full care of the client is not the most appropriate action in this situation. The UAP is already wearing a gown and gloves, which are part of the standard precautions for any patient care.The UAP just needs to add a face mask to their personal protective equipment (PPE) to safely assist the client.

Choice D rationale:

Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is always a good practice. However, it does not address the immediate need for the UAP to wear a face mask while in close contact with the client. Therefore, it is not the most appropriate action in this situation.

Choice A rationale:
Contractures are a risk for this client due to the lack of movement and constant positioning on one side. Contractures occur when the muscles, tendons, or ligaments shorten and tighten, limiting range of motion and flexibility. This can be a result of prolonged immobility or lack of use of the muscles.
Choice B rationale:
Calcium resorption is not a risk for this client. Calcium resorption refers to the process where bone tissue is broken down and calcium is released into the bloodstream. This process is not directly related to immobility or multiple sclerosis.
Choice C rationale:
Hypocalcemia, or low calcium levels in the blood, is also not a direct risk for this client. While immobility can lead to bone loss over time, it does not directly cause hypocalcemia.
Choice D rationale:
Diarrhea is not a risk for this client based on the information provided. Diarrhea can be a symptom of many conditions but there is no indication in the scenario that this client is at risk.
Choice E rationale:
Urinary stasis is a risk for this client due to their immobility. When a person is immobile, urine can pool in the bladder, creating an environment where bacteria can grow, potentially leading to urinary tract infections.

Choice F rationale:
Hypertension, or high blood pressure, is not a direct risk for this client based on the information provided. While chronic diseases like multiple sclerosis can indirectly contribute to hypertension through stress or medication side effects, it’s not directly caused by immobility or multiple sclerosis.

Choice G rationale:

Pressure injury is a significant risk for this client due to their constant positioning on one side and refusal to change positions. Pressure injuries occur when there is prolonged pressure on one area of the body, restricting blood flow and leading to tissue damage and necrosis.

Choice H rationale:

Atelectasis, or collapse of part of the lung, is also a risk for this client due to their immobility. When a person is immobile, they may take shallow breaths which do not fully inflate the lungs, leading to areas of collapse.