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

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is choice D. The client is oriented times three.

This means that the client knows who they are, where they are, and what time it is. This indicates a high level of consciousness and a normal Glasgow coma scale (GCS) rating of 15.

Choice A is wrong because the client withdraws from pain.

This means that the client reacts to a painful stimulus by pulling away from it. This indicates a lower level of consciousness and a GCS rating of 4 for motor response.

Choice B is wrong because the client is unable to obey commands.

This means that the client does not follow simple instructions such as moving a limb or opening their eyes. This indicates a lower level of consciousness and a GCS rating of 1 or 2 for motor response.

Choice C is wrong because the client opens eyes to sound.

This means that the client does not open their eyes spontaneously, but only when they hear a loud noise. This indicates a lower level of consciousness and a GCS rating of 3 for eye opening.

The Glasgow coma scale is a clinical tool used to assess the level of consciousness of a person after a brain injury.

It consists of three tests: eye opening, verbal response, and motor response.

Each test has a score range from 1 to 6, with higher scores indicating higher levels of consciousness. The total score ranges from 3 to 15, with lower scores indicating higher risk of death.

A. Select a site on the client’s dominant arm B. Apply a tourniquet below the venipuncture site C. Elevate the client’s arm prior to insertion D. Choose a vein that is palpable and straight

Correct Answer is D

Explanation

The correct answer is choice D. The nurse should choose a vein that is palpable and straight for IV catheter insertion.

This will facilitate the insertion of the catheter and reduce the risk of complications such as infiltration, phlebitis, or hematoma. A straight vein will also allow the catheter to be inserted up to the hub, which reduces the risk of contamination along the length of the catheter.

Choice A is wrong because selecting a site on the client’s dominant arm can interfere with the client’s mobility and increase the risk of dislodging the catheter. The nurse should choose a site on the client’s non-dominant arm, preferably on the hand or forearm.

Choice B is wrong because applying a tourniquet below the venipuncture site will impede blood flow and make it harder to locate a suitable vein. The nurse should apply a tourniquet above the venipuncture site, about 10 to 15 cm from the insertion site.

Choice C is wrong because elevating the client’s arm prior to insertion will decrease venous filling and make it harder to palpate a vein. The nurse should lower the client’s arm below the level of the heart to increase venous distension.

Normal ranges for IV catheter size and insertion angle depend on several factors, such as the type and duration of therapy, the condition and size of the vein, and the age and preference of the client.

In general, smaller gauge catheters (20 to 24) are preferred for peripheral IV therapy, and larger gauge catheters (14 to 18) are used for rapid fluid administration or blood transfusion. The insertion angle can vary from 10 to 30 degrees, depending on the depth and location of the vein.

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A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?

Nursing Test Bank

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A nurse is admitting an adolescent who has rubella.

Which of the following actions should the nurse take?