A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

Administer aspirin if the client develops a fever.

Initiate contact precautions for the client.

Assign the client to a negative-pressure airflow room.

Have visitors remain at least 0.91 m (3 feet. away from the client.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Assign the client to a negative-pressure airflow room.

Choice A rationale:

Administering aspirin to a client with varicella zoster is not recommended due to the risk of Reye’s syndrome, a serious condition that can cause swelling in the liver and brain.

Choice B rationale:

While contact precautions are important, varicella zoster also requires airborne precautions due to its highly contagious nature. This means that simply initiating contact precautions is not sufficient.

Choice C rationale:

Assigning the client to a negative-pressure airflow room is crucial because it helps contain the airborne virus and prevents it from spreading to other areas of the hospital.

Choice D rationale:

Having visitors remain at least 0.91 m (3 feet) away from the client is a good practice, but it is not sufficient on its own to prevent the spread of the virus. Airborne precautions, including a negative-pressure room, are necessary.

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Correct Answer is B

Explanation

A. Incorrect. The closure of the posterior fontanel by 23 months is a normal developmental milestone.
B. Correct. The anterior fontanel typically closes by 12 to 18 months of age. If it closes prematurely, it could be a sign of craniosynostosis and should be assessed by the provider.
C. Incorrect. Rolling from the back to the abdomen is a normal developmental milestone at around 46 months of age.
D. Incorrect. Moving objects to the mouth is a normal developmental behavior in infants as they explore their environment through sensory input.

A. Initiate droplet precautions. B. Administer granulocyte colony-stimulating factor. C. Educate the infant's guardians about exchange transfusions. D. Monitor the infant's lymphocyte count.

Correct Answer is D

Explanation

A. Droplet precautions are not indicated for HIV; standard precautions should be followed.
B. Granulocyte colony-stimulating factor is typically used to increase white blood cell production and is not directly related to HIV care.
C. Exchange transfusions are not a routine intervention for infants with HIV.
D. Correct. Monitoring the infant's lymphocyte count is important to assess immune function and response to HIV treatment.

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A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

Nursing Test Bank

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