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
The correct answer is choice B. Isolate the client from staff who are pregnant. Choice A rationale: Aspirin should not be administered to children or adolescents with viral infections like rubella due to the risk of Reye's syndrome, a potentially fatal condition that causes liver and brain damage. Choice B rationale: Rubella (German measles) is particularly dangerous for pregnant women because it can cause congenital rubella syndrome in the fetus, leading to severe birth defects. Therefore, isolating the client from pregnant staff is crucial to prevent exposure. Choice C rationale: Airborne precautions are not necessary for rubella. Rubella is transmitted through respiratory droplets, so droplet precautions, not airborne precautions, are appropriate. Choice D rationale: Koplik spots are associated with measles (rubeola), not rubella. Therefore, monitoring for Koplik spots is not relevant for a client with rubella.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Instruct the client to avoid coughing during the procedure.
A thoracentesis is a procedure that involves inserting a needle into the pleural space to remove excess fluid or air. Coughing can increase the risk of pneumothorax (collapsed lung) or bleeding during the procedure.
Choice B is wrong because the client does not need to be NPO (nothing by mouth) for 6 hr prior to the procedure. There is no risk of aspiration during a thoracentesis.
Choice C is wrong because the client should be positioned on the unaffected side for 4 hr following the procedure. This allows the affected lung to re-expand and prevents fluid from accumulating in the pleural space again.
Choice D is wrong because the client should not be placed in the prone position during the procedure. The prone position makes it difficult to access the pleural space and can compromise breathing.
Correct Answer is B
Explanation
The correct answer is choice B. Increase exercise.
Exercise can help stimulate bowel movements and prevent constipation, which is a common side effect of opioid medications.
Exercise can also improve blood circulation, reduce stress, and enhance mood, which can benefit clients who have chronic pain.
Choice A is wrong because decreasing insoluble fiber intake can worsen constipation.
Insoluble fiber adds bulk to the stool and helps it pass more easily through the colon.
Clients who take opioid medications should increase their intake of insoluble fiber from sources such as whole grains, fruits, vegetables, nuts, and seeds.
Choice C is wrong because drinking less water can lead to dehydration and hardening of the stool, which can make it more difficult to pass.
Clients who take opioid medications should drink plenty of water to keep the stool soft and moist.
Choice D is wrong because taking a laxative every day can cause dependence, tolerance, and electrolyte imbalance.
Laxatives should be used only as a last resort and under the guidance of a health care provider.
Clients who take opioid medications should try other methods of preventing constipation first, such as increasing exercise, fiber, and water intake.
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