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 B
Explanation
Explanation
B.Hypertension
Tranylcypromine is a monoamine oxidase inhibitor (MAOI) used to treat depression. One of the potential adverse effects of MAOIs is hypertensive crisis, which can be triggered by the consumption of foods high in tyramine. Tyramine-rich foods, such as aged cheeses, cured meats, certain wines, and fermented products, can cause the release of norepinephrine, leading to a sudden increase in blood pressure.
Monitoring the client for hypertension is crucial because a hypertensive crisis can be life-threatening. Signs and symptoms of hypertensive crisis may include severe headache, chest pain, palpitations, blurred vision, anxiety, and shortness of breath. If these symptoms occur, immediate medical intervention is required.
The other options are not specifically associated with the adverse effects of tranylcypromine:
Hyperglycemia in (option A) is not typically associated with tranylcypromine. However, it is important to monitor blood glucose levels in clients with pre-existing diabetes, as tranylcypromine can affect blood sugar control.
Hematuria (blood in the urine) in (option C) is not a common adverse effect of tranylcypromine.
Tinnitus (ringing in the ears) in (option D) is not a commonly reported adverse effect of tranylcypromine.
Correct Answer is B
Explanation
Prednisone can cause blood glucose levels to increase.
The nurse should explain to the client that the reason for checking his blood glucose level is because prednisone, a medication he is receiving, can cause an increase in blood glucose levels. Prednisone is a corticosteroid medication that is commonly used in the treatment of various conditions, including COPD. It has the potential to raise blood glucose levels by promoting gluconeogenesis (the production of glucose from non-carbohydrate sources) and decreasing insulin sensitivity. Monitoring blood glucose levels is important to assess and manage any potential hyperglycaemia or changes in the client's blood sugar levels while on prednisone.
Older adults are not at increased risk for developing type 1 diabetes mellitus in (option A) is incorrect. Type 1 diabetes is an autoimmune condition that typically occurs in childhood or adolescence, and it is characterized by the destruction of insulin-producing cells in the pancreas.
Albuterol treatments, which are used to relieve bronchospasms in clients with COPD, are not known to cause blood glucose levels to decrease in (option C) is incorrect. Albuterol is a beta-2 adrenergic agonist that primarily acts on the respiratory system and does not have a direct effect on blood glucose levels.
Having COPD does not directly cause blood glucose levels to fluctuate in (option D) is incorrect. While there can be various factors that may indirectly affect blood glucose levels in individuals with COPD (e.g., medications, stress, comorbidities), the primary reason for monitoring blood glucose in this case is the use of prednisone.
In summary, the nurse should explain to the client that the blood glucose levels are being checked because prednisone, a medication he is taking for his COPD, can cause an increase in blood glucose levels. This allows for appropriate monitoring and management of any potential hyperglycemia associated with the use of prednisone.
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