A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?
Administer aspirin to the client.
Isolate the client from staff who are pregnant.
Initiate airborne precautions.
Monitor for the development of Koplik spots.
The Correct Answer is B
This is because rubella is a highly contagious viral infection that can cause serious harm to the developing fetus if the pregnant person gets infected. Rubella can cause congenital rubella syndrome, which can result in hearing and vision loss, heart defects and other serious conditions in newborns.
Choice A is wrong because aspirin should not be given to children or adolescents with viral infections, as it can cause Reye’s syndrome, a rare but potentially fatal condition that affects the liver and brain.
Choice C is wrong because rubella does not require airborne precautions, which are used for diseases that can spread through very small droplets that can remain in the air for long periods of time, such as tuberculosis or measles. Rubella spreads through direct contact with saliva or mucus of an infected person, or through respiratory droplets from coughing or sneezing.
Therefore, standard and droplet precautions are sufficient to prevent transmission. Choice D is wrong because Koplik spots are a characteristic sign of measles, not rubella.
Koplik spots are small white spots that appear on the inside of the cheeks before the measles rash develops. Rubella causes a pink or red rash that usually starts on the face and moves down the body.
Normal ranges for rubella antibody tests are:
- IgM: Negative or less than 0.9 IU/mL
- IgG: Negative or less than 10 IU/mL
A positive IgM result indicates a recent or current infection, while a positive IgG result indicates a past infection or immunity from vaccination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
Answer is…
The following provider prescriptions are anticipated or contraindicated for the client:.
- Insert an indwelling urinary catheter. Anticipated. This prescription is anticipated because the client may have oliguria or anuria due to dehydration, hypovolemia, or renal impairment caused by pancreatitis. A urinary catheter can help monitor the urine output and fluid status of the client.
- Insert a nasogastric tube and maintain low intermittent suction. Anticipated. This prescription is anticipated because the client may have nausea, vomiting, and abdominal distension due to pancreatitis. A nasogastric tube can help decompress the stomach, reduce pancreatic stimulation, and prevent aspiration.
- Administer lactated Ringer’s 1 L via IV bolus. Anticipated. This prescription is anticipated because the client may have hypovolemia, hypotension, and electrolyte imbalances due to pancreatitis. Lactated Ringer’s solution can help restore fluid and electrolyte balance, improve tissue perfusion, and prevent shock.
- Administer famotidine 20 mg via intermittent IV infusion twice daily. Anticipated. This prescription is anticipated because the client may have gastric hypersecretion and peptic ulcer disease due to pancreatitis. Famotidine is a histamine-2 receptor antagonist that can help reduce gastric acid production, protect the gastric mucosa, and promote healing of ulcers.
Correct Answer is B
Explanation
A hematoma is a collection of blood outside a blood vessel that can cause swelling, pain, and bruising. It can indicate bleeding from the artery where the catheter was inserted, which can be a serious complication of cardiac catheterization.
The nurse should notify the provider immediately if a hematoma is observed.
Choice A is wrong because a heart rate of 90/min is within the normal range for adults and does not indicate a complication.
Choice C is wrong because bounding pulses in the affected extremity are expected after cardiac catheterization, as they indicate good blood flow to the area.
Choice D is wrong because the report of discomfort at the insertion site is common and usually mild after cardiac catheterization.
The nurse can provide pain relief as needed but does not need to notify the provider unless the pain is severe or persistent.
Normal ranges for heart rate are 60-100 beats per minute for adults. Normal ranges for blood pressure are 120/80 mmHg or lower for systolic pressure and 80 mmHg or lower for diastolic pressure. Normal ranges for oxygen saturation are 95-100% for adults.
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