A nurse is caring for a client who has shingles with multiple skin lesions. Which of the following actions by the nurse require intervention nurse's supervisor?
The nurse wears gloves when providing direct care to the patient.
The nurse admits another client who has shingles to the client’s double room.
The nurse wears a gown when bathing the client.
The nurse wears an N95 respirator mask
The Correct Answer is B
Choice A rationale: Wearing gloves is appropriate when providing direct care to a client with shingles to prevent the spread of the virus.
Choice B rationale: Shingles is caused by the varicella-zoster virus, and it is highly contagious. Placing a client with shingles in a double room increases the risk of spreading the virus to other clients, especially those with compromised immune systems.
Choice C rationale: Wearing a gown is appropriate when there is a risk of contact with the client's lesions to prevent the spread of the virus.
Choice D rationale: While wearing a mask may be indicated for certain respiratory conditions, it is not typically required when caring for a client with shingles.
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Correct Answer is C
Explanation
Choice A rationale: this is important to assess the individual’s blood level and risk of infection but it is not a priority action compared to airway management.
Choice B rationale: The insertion of an indwelling urinary catheter is crucial for urine output monitoring but is not a priority action to take.
Choice C rationale: Inspection of the mouth for signs of inhalation injuries is a priority action for burns patients, especially those who have sustained facial burns since they can result in airway compromise and subsequent respiratory failure. The signs to look out for include; soot in the mouth and mouth, hoarseness, stridor, wheezes, or singed nasal hairs. In cases of suspected inhalation injuries, the nurse should inform the healthcare provider to assess for the need for intubation.
Choice D rationale: administration of analgesics is crucial for pain relief for all burn patients. However, this is not a priority action to take compared to airway management.
Correct Answer is B
Explanation
Choice A rationale: While impaired tissue perfusion can affect activity tolerance, addressing the underlying perfusion issue takes precedence.
Choice B rationale: Varicose veins with ulcerations and lower extremity edema suggest impaired tissue perfusion. The compromised blood flow can lead to poor oxygenation and nutrient delivery to tissues, increasing the risk of ulceration and delayed wound healing.
Choice C rationale: Impaired tissue perfusion contributes to impaired skin integrity, but it is not the primary issue.
Choice D rationale: While varicose veins can impact body image, addressing impaired tissue perfusion is more critical for the client's overall well-being.
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