A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection?

Administer metronidazole.

Don protective eyewear before entering the room.

Wear a mask when working within 3 feet of the client.

Place the client in a negative airflow room.

Answer and Explanation

The Correct Answer is C

C. Wearing a mask when working within close proximity to the client helps prevent the transmission of respiratory droplets containing the influenza virus. This is especially important when providing direct care to the client, such as during assessments or procedures.
A. Metronidazole is an antibiotic used to treat bacterial infections, not viral infections like influenza. Administering metronidazole would not prevent the spread of influenza.
B. Protective eyewear is typically used to prevent exposure to bloodborne pathogens or other bodily fluids that could splash into the eyes. In the case of influenza, the primary mode of transmission is through respiratory droplets, so protective eyewear is not necessary for preventing its spread.
D. Negative airflow rooms are typically used for clients with airborne infections, such as tuberculosis, where there is a risk of droplet nuclei remaining suspended in the air for prolonged periods. Influenza is primarily spread through respiratory droplets and does not require negative airflow isolation.

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Correct Answer is A

Explanation

A. Keeping the client's heels off the mattress helps prevent pressure injuries, particularly heel ulcers, which are common in clients who are immobile or on bed rest. Pressure on the heels can impede blood flow and lead to tissue damage, especially if the client remains in the same position for an extended period.
B.Repositioning the client is also important for preventing pressure injuries, as it helps redistribute pressure and relieve pressure on vulnerable areas of the body. However, it should be done more frequently.
C. Raising the head of the client's bed to a 60° angle is not directly related to preventing pressure injuries. While elevating the head of the bed may provide comfort and facilitate breathing for some clients, it does not address pressure distribution or protection of bony prominences.
D. Massaging the client's bony prominences is contraindicated for preventing pressure injuries. Massaging bony prominences can increase friction and shear forces on the skin, which may actually exacerbate the risk of pressure injury development.

A. Keep the client's room temperature at 18° C (64.4° F). B. Place the bedside table 0.9 m (3 feet) away from the bed. C. Provide the client with a night light. D. Elevate full-length side rails on both sides of the client's bed.

Correct Answer is C

Explanation

C. Providing the client with a night light helps improve visibility during nighttime ambulation, reducing the risk of falls. Many falls in healthcare settings occur during nighttime when visibility is reduced.
A. Keeping the client's room temperature at 18°C (64.4°F) is not directly related to fall prevention. While maintaining a comfortable room temperature is important for the client's overall comfort, it does not specifically address fall risk.

B. Placing the bedside table 0.9 m (3 feet) away from the bed is not directly related to fall prevention. While organizing the client's environment to ensure accessibility and safety is important, the distance of the bedside table from the bed is less critical compared to other fall prevention measures.
D. Elevating full-length side rails on both sides of the client's bed is not recommended as a fall prevention measure. The use of side rails can increase the risk of falls and should be used judiciously, if at all, based on the client's individual risk assessment. Full-length side rails can create entrapment hazards and may not effectively prevent falls.

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A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection?

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Naxlex Comprehensive Predictor Exams

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