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?
Assign the client to a negative pressure airflow room
Have visitors remain at least 0.91 m (3 feet) away from the client
Initiate contact precautions for the client
Administer aspirin if the client develops a fever
Correct Answer : A,C
Varicella zoster is highly contagious, and airborne precautions should be implemented. Assigning the client to a negative pressure airflow room helps prevent the spread of the virus to others by containing and filtering the air within the room.
In addition to airborne precautions, contact precautions should also be implemented. This includes using gloves and gowns when providing care to the client to minimize direct contact with infectious materials.

The other options listed are not appropriate interventions for a client with varicella zoster: While it is important to minimize close contact with an infectious client, varicella zoster is primarily transmitted through airborne droplets. Visitors should follow the appropriate precautions, such as wearing masks and adhering to hand hygiene, rather than just maintaining a certain distance.
Aspirin should not be given to clients with varicella zoster, especially children, due to the risk of developing Reye's syndrome. Reye's syndrome is a rare but serious condition that can cause swelling in the liver and brain. Acetaminophen (paracetamol) is typically recommended for managing fever in clients with varicella zoster.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Provide the client with written information about advance directives: It is important for the nurse to educate the client about advance directives, their purpose, and how they can make informed decisions about their healthcare.
Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should explain to the client that an advance directive is a legally binding document that guides healthcare decisions, and it must be respected and followed by healthcare providers.
Communicate advance directives status via the medical record and shift report: The nurse should ensure that the client's advance directives status is accurately documented in the medical record and communicated to other members of the healthcare team during shift handoffs. This helps ensure that the client's wishes are known and respected by all involved in their care.
Initiate a power of attorney for health care document: The nurse can assist the client in initiating a power of attorney for healthcare document if the client wishes to appoint someone as their healthcare proxy or agent. This document designates someone to make medical decisions on behalf of the client if they become unable to do so.
The other options listed are not appropriate or accurate in relation to the responsibilities of the nurse regarding advance directives:
Document that the provider discussed-do-not-resuscitate status with the client: While discussing do-not-resuscitate (DNR) status may be part of the advance care planning process, it is not directly related to advance directives as a whole.
Inform the client that an advance directive discontinues further care: This statement is incorrect and misleading. An advance directive does not automatically discontinue care but rather guides the provision of care according to the client's wishes.
Correct Answer is C
Explanation
The presence of edema and coolness around the catheter's insertion site suggests that infiltration may have occurred. Infiltration refers to the unintended leakage of fluid into the surrounding tissues instead of flowing into the vein. It can lead to tissue damage and compromised circulation. Stopping the infusion is the initial priority to prevent further infiltration and minimize potential harm to the client.
Applying a warm compress may be appropriate to promote comfort and circulation in some cases, but it should be done after stopping the infusion and assessing the severity of the infiltration.
Documenting the infiltration is necessary for accurate record-keeping and to communicate the occurrence to the healthcare team. However, it is not the first immediate action required in this situation.
Elevating the arm can help reduce swelling and promote venous return. It can be done after stopping the infusion, but it is not the first action to address the potential infiltration.
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