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 E
Explanation
Adequate fluid intake helps to soften the stool, prevent constipation, and ease bowel movements. It can also help with bladder function and prevent urinary tract infections. This intervention is particularly relevant given the client's complaint of abdominal cramping and a small, hard, painful bowel movement.
The other options are not appropriate based on the information provided:
- "Encourage prolonged dangling before ambulation" is not necessary or relevant in this case. The client is already transferring out of bed to a chair independently and ambulating independently in the hallway, indicating sufficient mobility.
- "Irrigate indwelling catheter with 500 mL of fluid" is not indicated based on the provided information. The urinary catheter is intact, and the client is producing an appropriate amount of urine. There is no indication of urinary retention or need for irrigation.
- "Administer an enema" is not necessary at this point. The client has reported a small, hard, painful bowel movement, which indicates constipation. However, conservative measures such as encouraging oral fluid intake and possibly adding dietary fiber should be tried first before considering an enema.
- "Assist the client with a sitz bath" is not directly related to the client's current symptoms. A sitz bath is typically used for perineal hygiene, pain relief, or healing after certain surgical procedures, but it does not address the reported abdominal cramping or constipation.
Correct Answer is D
Explanation
The APN, also known as a nurse practitioner or clinical nurse specialist, has advanced knowledge and expertise in pharmacology and medication management. They are trained to assess medication interactions, evaluate potential risks, and provide guidance to ensure safe and effective medication use.
The other members of the interdisciplinary team listed are not specifically trained to address medication interactions:
Social workers focus on addressing psychosocial aspects of care, such as emotional support, counseling, and resource coordination. While they may provide valuable assistance in various areas of the client's care, they typically do not have specialized knowledge in medication interactions.
Patient care technicians, also known as nursing assistants or certified nursing assistants, provide direct patient care under the supervision of nurses. They do not typically have the training or authority to address medication interactions.
Psychologists specialize in the assessment, diagnosis, and treatment of mental and emotional health concerns. While they may be involved in the client's overall care, including medication management for mental health conditions, their expertise lies primarily in psychological assessment and therapy rather than medication interactions.
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