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","B","C","D","H"]
Explanation
- A. Heart rate: The client’s heart rate is elevated at 118/min, which could indicate blood loss, dehydration, pain, anxiety, or infection. This finding requires immediate follow-up to assess the cause and intervene as needed.
- B. Current medications: The client is taking ibuprofen 800 mg three times daily PRN for arthritis pain. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastric irritation, ulceration, and bleeding. This finding requires immediate follow-up to evaluate the client’s pain level, medication use, and possible alternatives to NSAIDs.
- C. Blood pressure: The client’s blood pressure is low at 90/50 mm Hg, which could indicate hypovolemia, shock, or cardiac dysfunction. This finding requires immediate follow-up to monitor the client’s fluid status, perfusion, and organ function.
- D. Stool results: The client’s stool tested positive for occult blood and H. pylori bacteria. Occult blood indicates gastrointestinal bleeding, which could be related to the client’s abdominal pain and weight loss. H. pylori is a common cause of peptic ulcer disease, which can also cause bleeding and pain. This finding requires immediate follow-up to confirm the diagnosis and initiate treatment with antibiotics and acid-suppressing drugs.
- H. Hemoglobin and hematocrit: The client’s hemoglobin and hematocrit are low at 9.1 g/dL and 27%, respectively. These values indicate anemia, which could be caused by chronic blood loss, nutritional deficiency, or bone marrow suppression. This finding requires immediate follow-up to determine the etiology and severity of the anemia and provide appropriate therapy such as blood transfusion, iron supplementation, or erythropoietin.
The other findings are not as urgent as the ones above:
- E. Respiratory rate: The client’s respiratory rate is normal at 18/min. There is no evidence of respiratory distress or hypoxia.
- F. WBC count: The client’s WBC count is normal at 6,700/mm3. There is no indication of infection or inflammation.
- G. Temperature: The client’s temperature is slightly elevated at 37.5° C (99.5° F), but not enough to warrant immediate concern. It could be due to stress, dehydration, or a mild infection. The nurse should monitor the temperature trend and report any significant changes or signs of sepsis.
Correct Answer is B
Explanation
The correct answer is b. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
Choice A rationale:
- Statement:“I should take antibiotics when I have a virus.”
- Rationale:This statement is incorrect.Antibiotics are medications that fight bacteria,not viruses.Taking antibiotics when you have a virus will not help you get better and can actually lead to antibiotic resistance.
Choice B rationale:
- Statement:“I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
- Rationale:This statement is correct.Chickenpox is a highly contagious virus that is spread through the air by coughing and sneezing.However,a person with chickenpox is no longer contagious once all of the sores have crusted over.This typically happens about 5 days after the rash first appears.
Choice C rationale:
- Statement:“I should wash my hands for 10 seconds with hot water after working in the garden.”
- Rationale:This statement is partially correct.Handwashing is an important way to prevent the spread of infection.However,the water does not need to be hot.Warm or cold water is just as effective.It is also important to wash your hands for at least 20 seconds,not 10 seconds.
Choice D rationale:
- Statement:“I can clean my cat’s litter box during my pregnancy.”
- Rationale:This statement is incorrect.Cat feces can contain a parasite called Toxoplasma gondii,which can cause a serious infection called toxoplasmosis.Toxoplasmosis can be harmful to a developing baby.It is best to avoid cleaning cat litter boxes during pregnancy.If you must clean the litter box,wear gloves and wash your hands thoroughly afterwards.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.