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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Using the overbed trapeze helps the client strengthen their upper body and improve mobility by allowing them to independently move and reposition themselves in bed. This promotes independence in activities of daily living and reduces reliance on nursing assistance.

Cautioning the client to avoid a prone position while in bed is important for preventing pressure ulcers and maintaining proper positioning, but it does not specifically promote independence and mobility.

Keeping a loose, absorbent dressing over the surgical site is important for wound care and infection prevention, but it does not directly promote mobility or independence. Maintaining abduction of the client's residual limb with a pillow is important to prevent contractures, but it does not directly promote mobility or independence.

A. Release the client's restraints every 4 hr. B. Check the client's status every hour. C. Document the client's behavior leading to the initiation of the restraints. D. Obtain written consent by the client for the placement of the restraints.

Correct Answer is C

Explanation

Document the client's behavior leading to the initiation of the restraints: Accurate and comprehensive documentation is essential in the client's medical record. This includes documenting the client's behavior or actions that necessitated the use of restraints. It is important to document the reason, duration, and type of restraint used.

Release the client's restraints every 2 hours or as per institutional policy: It is important to periodically release the restraints to assess the client's circulation, skin integrity, and overall well-being. Restraints should never be kept on continuously without intermittent release. Check the client's status every 15 minutes: The nurse should closely monitor the client's vital signs, level of comfort, and any signs of distress or complications. Frequent assessment ensures early identification and intervention if any issues arise.

Obtain informed consent: While obtaining consent is necessary for many procedures or treatments, including the use of restraints, it is not applicable in situations where there is an imminent risk of harm to the client or others. The use of restraints in mental health units is based on legal and ethical guidelines, prioritizing the client's safety and the safety of others.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

Correct Answer is C

Explanation

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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?