A nurse is caring for a client who has the communicable disease influenza. Which of the following isolation precautions should the nurse take?

Double-bag the client's trash before removing it from the room.

Place the client in a negative air pressure room with 6 to 12 air exchanges per hour.

Ensure all air in the client's room is filtered through a HEPA filter.

Wear a surgical mask when within 1 m (3 ft) of the client.

Answer and Explanation

The Correct Answer is D

A) Double-bag the client's trash before removing it from the room: While double-bagging is a precaution used in certain infections to prevent contamination, it is not necessary for influenza. Influenza spreads via respiratory droplets rather than contact with contaminated objects. Standard waste disposal methods are typically sufficient to manage the risk of contamination from trash.

B) Place the client in a negative air pressure room with 6 to 12 air exchanges per hour: Negative air pressure rooms are designed to contain airborne pathogens by preventing contaminated air from escaping the room. Diseases such as tuberculosis or measles require this level of isolation. However, influenza spreads through droplets that settle quickly rather than remaining airborne, making negative air pressure rooms unnecessary for influenza isolation.

C) Ensure all air in the client's room is filtered through a HEPA filter: HEPA (High-Efficiency Particulate Air) filters are used to trap airborne particles. For influenza, which is spread by larger respiratory droplets, such filtration is not needed. The droplets are too large to remain suspended in the air and are typically spread through close contact, rather than requiring air filtration.

D) Wear a surgical mask when within 1 m (3 ft) of the client: This is the most appropriate precaution. Influenza is primarily spread through respiratory droplets that can travel about 1 meter (3 feet) when a person coughs, sneezes, or talks. Wearing a surgical mask within this distance helps prevent inhaling these droplets, thus reducing the risk of transmission. This aligns with droplet precautions which are standard for managing influenza.

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Correct Answer is D

Explanation

A) Bounding peripheral pulses: Metabolic acidosis typically does not cause bounding peripheral pulses. In metabolic acidosis, vasodilation might occur, but it usually leads to weaker, not bounding, pulses due to decreased cardiac output and blood pressure.

B) Hyperreflexia: Hyperreflexia is not commonly associated with metabolic acidosis. Instead, metabolic acidosis may cause symptoms like muscle weakness or fatigue due to the effect of acid-base imbalance on neuromuscular function.

C) Cool skin: While cool skin can sometimes be associated with poor perfusion in severe cases, it is not a direct manifestation of metabolic acidosis. Metabolic acidosis more commonly affects internal physiology rather than peripheral skin temperature directly.

D) Hypotension: Hypotension is a common manifestation of metabolic acidosis. The acidosis leads to vasodilation and decreased cardiac contractility, resulting in a drop in blood pressure. This is a critical sign for the nurse to monitor as it indicates the severity of the acid-base imbalance and its effect on the cardiovascular system.

A. Cimetidine B. Calcitonin C. Sodium bicarbonate D. Sodium chloride

Correct Answer is C

Explanation

A) Cimetidine: Cimetidine is an H2 receptor antagonist used to reduce stomach acid and treat conditions such as peptic ulcers and gastroesophageal reflux disease (GERD). It is not used to manage metabolic acidosis.

B) Calcitonin: Calcitonin is used to regulate calcium levels and treat conditions like osteoporosis or hypercalcemia. It does not address metabolic acidosis and is not appropriate for this condition.

C) Sodium bicarbonate: Sodium bicarbonate is commonly used to treat metabolic acidosis. It works by neutralizing excess acid in the blood, thereby increasing the blood's pH and helping to correct the acid-base imbalance associated with metabolic acidosis.

D) Sodium chloride: Sodium chloride is a salt that can be used to manage fluid and electrolyte imbalances but does not correct metabolic acidosis. It is not suitable for treating the acid-base imbalance seen in metabolic acidosis.

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A nurse is caring for a client who has the communicable disease influenza. Which of the following isolation precautions should the nurse take?

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