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.Restraints should be released more frequently, typically every 2 hours, to assess circulation, skin integrity, and range of motion, and to provide an opportunity for toileting and other needs.

B.It is essential to document the specific behaviors that led to the use of restraints, as this provides a clear rationale for why the restraints were necessary. This documentation is important for legal and clinical reasons and helps ensure that restraints are used appropriately and only when absolutely necessary.

C.Clients are not required to provide written consent for the use of restraints, especially in situations where restraints are necessary to protect the client or others from immediate harm. However, the nurse must follow the facility's protocol, which usually involves obtaining a physician's order and documenting the justification for the restraint use.

D.The nurse should check the client's status more frequently, typically every 15 minutes, to ensure the client's safety and well-being while in restraints.

A. Hyperglycemia B. Hand tremors C. Nausea D. Shortness of breath

Correct Answer is D

Explanation

A. Incorrect. Epinephrine is not used to treat hyperglycemia.
B. Incorrect. Epinephrine is not used to treat hand tremors.
C. Incorrect. Epinephrine is not used to treat nausea.
D. Correct. Epinephrine is used to treat severe allergic reactions, including anaphylaxis, which can involve manifestations such as shortness of breath, difficulty breathing, and wheezing.

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