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 A

Explanation

A. Correct. Providing information about the client's pain relief strategies and positioning preferences helps ensure continuity of care and optimal comfort for the client.

B. Incorrect. While medication administration is important, it's not as relevant for the change of shift report as information related to the client's condition, preferences, and care needs.

C. Incorrect. The client's family history of breast cancer is not the most critical information for the immediate care of the client and can be discussed during a more comprehensive assessment.

D. Incorrect. Although family support and visits are important, the duration of the partner's visit is not as relevant as the client's immediate care needs and preferences.

A. An approximate amount of urine was recorded after the urine leaked from the client's catheter bag. B. A client received an 0900 daily medication at 1000. C. A client who has an infection refused the evening meal. D. A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing. E. A client fell when ambulating to the bathroom alone.

Correct Answer is ["A","B","E"]

Explanation

The nurse should write an incident report for the following events:
1. An approximate amount of urine was recorded after the urine leaked from the client's catheter bag. This indicates a potential issue with the catheter or its proper functioning, which needs to be documented and addressed.
2. A client received an 0900 daily medication at 1000. This is a medication administration error as the medication was given later than the prescribed time. Medication errors should be reported and documented to ensure proper follow-up and prevent future occurrences.
3. A client fell when ambulating to the bathroom alone. Falls are considered significant incidents and should always be documented and reported to ensure appropriate evaluation, intervention, and prevention of future falls.
The following events do not require an incident report:
A client who has an infection refused the evening meal. While it is important to document a client's refusal of meals, it does not typically warrant an incident report unless there are specific concerns related to the client's health or safety.

A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing. This may not require an incident report unless there are specific

circumstances or contraindications related to the timing of the antibiotic administration and blood collection, which need to be documented and reviewed.

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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

Naxlex Comprehensive Predictor Exams

A nurse is providing change of shift report for a client. Which of the following information should the nurse include in the report?

Correct Answer is A

Explanation

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Correct Answer is ["A","B","E"]

Explanation

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