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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","F"]
Explanation
A. Oxygen saturation level: The client is restless, not following commands, and has labored respirations with crackles and wheezes in the breath sounds. Monitoring the oxygen saturation level is essential to assess the client's respiratory status and oxygenation.
B. Tremors: The client has tremors in their hands. Considering the client's history of Parkinson's disease, changes in tremors should be monitored and addressed promptly.
C. The immediate concern is addressing the respiratory distress.
D. Heart rate may also be monitored, but it's not as critical in this context.
E. Chronic health conditions are relevant for the overall care plan, but they do not require immediate intervention as compared to respiratory and tremor issues.
F. Respiratory rate: The client has labored respirations and abnormal breath sounds (crackles and wheezes). Monitoring the respiratory rate is important to evaluate the client's breathing pattern and respiratory distress.
Correct Answer is C
Explanation
A. Incorrect. Irrigation of a wound with antibiotic solution typically does not require informed consent.
B. Incorrect. Insertion of a nasogastric tube does not usually require informed consent unless it involves specific risks or is part of a research protocol.
C. Correct. Placement of a central venous catheter is an invasive procedure that involves risks, and informed consent is usually required.
D. Incorrect. Administration of an iron injection using the Z-track technique is a routine procedure and does not usually require informed consent.
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