A nurse is assisting in the admission of a client who has measles. Which of the following isolation precautions should the nurse initiate?
Contact.
Airborne.
Protective environment.
Droplet.
The Correct Answer is B
Choice A rationale:
Contact precautions are indicated when the client has a condition that can be easily transmitted through direct contact with the client or their environment. Measles, which is an airborne disease, requires more stringent precautions due to its mode of transmission.
Choice B rationale:
The correct choice. Measles is spread through airborne particles, making airborne precautions necessary. These precautions include placing the client in a negative pressure room, wearing appropriate respiratory protection (e.g., N95 mask), and ensuring that healthcare providers are properly protected from inhaling infectious particles.
Choice C rationale:
A protective environment is a specialized form of isolation used for clients with compromised immune systems, such as those undergoing stem cell transplants. It involves maintaining a sterile environment to prevent the introduction of pathogens. This level of precautions is not applicable to clients with measles.
Choice D rationale:
Droplet precautions are appropriate for diseases that are transmitted through respiratory droplets generated by coughing, sneezing, or talking. Measles, however, is transmitted through smaller airborne particles that can remain suspended in the air for longer periods, making airborne precautions the most suitable choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Implementing fluid restrictions is not recommended for a child with diabetic ketoacidosis (DKA). DKA is characterized by dehydration and electrolyte imbalances, and fluid replacement is a crucial aspect of its management. Restricting fluids could worsen dehydration and hinder the correction of metabolic imbalances.
Choice B rationale:
(Correct Choice) Monitoring vital signs every 8 hours is an important intervention for a school-age child with DKA. Vital signs, including heart rate, respiratory rate, blood pressure, and temperature, provide valuable information about the child's overall condition, fluid status, and response to treatment. More frequent monitoring might be necessary during the acute phase of DKA.
Choice C rationale:
Initiating continuous cardiac monitoring is not typically indicated for a school-age child with DKA. While DKA can have effects on the cardiovascular system, continuous cardiac monitoring is reserved for more critical situations where immediate changes in heart rhythm need to be detected.
Choice D rationale:
Administering subcutaneous insulin 30 minutes before meals is not appropriate for a child with DKA. In DKA management, insulin is typically administered intravenously to achieve more precise control over blood glucose levels. Subcutaneous insulin might not provide the rapid and consistent action needed to address the acute hyperglycemia and metabolic acidosis in DKA.
Correct Answer is A
Explanation
Choice A rationale:
Apply cold packs to the lower abdomen. This is the correct answer because applying cold packs to the lower abdomen can help alleviate dysmenorrhea (painful menstrual cramps). Cold therapy helps to constrict blood vessels, reducing blood flow to the area and thus reducing pain. It's a non-pharmacological approach to managing menstrual cramps.
Choice B rationale:
Increase daily intake of fat. Increasing fat intake is not a recommended approach for managing dysmenorrhea. Balanced nutrition is important, but increasing fat intake is unlikely to significantly impact menstrual cramps. Other strategies are more effective.
Choice C rationale:
Massage the lower back area. Massaging the lower back can help with muscle relaxation and may provide some relief, but it is not as effective as applying cold packs to the lower abdomen for dysmenorrhea. Cold packs specifically target blood flow reduction to the area of pain.
Choice D rationale:
Limit physical activity. While it's generally a good idea to avoid strenuous physical activity during periods of intense pain, limiting physical activity alone is not the most effective strategy for managing dysmenorrhea. Cold packs and other interventions are more likely to provide relief.
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