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 C

Explanation

A) Hispanic ethnicity: While ethnicity can influence the prevalence and risk of hypertension, Hispanic ethnicity alone is not a direct risk factor for hypertension. Other factors such as lifestyle, diet, and genetic predispositions play more significant roles in the development of hypertension.

B) Cholesterol 190 mg/dL: Although elevated cholesterol levels can contribute to cardiovascular disease, a cholesterol level of 190 mg/dL is considered borderline high but not a primary risk factor for hypertension. The risk for hypertension is more directly related to factors like blood pressure levels and weight.

C) BMI of 28: A Body Mass Index (BMI) of 28 falls into the overweight category, which is a known risk factor for developing hypertension. Excess body weight can increase blood pressure by increasing the workload on the heart and contributing to insulin resistance, which can further elevate blood pressure.

D) History of atrial fibrillation: While atrial fibrillation is a significant cardiac condition and can be associated with other cardiovascular risks, it is not a direct risk factor for the development of hypertension. The primary risk factors for hypertension include factors like obesity, diet, and physical inactivity.

A. Initiate frequent, short periods of exercise throughout the day. B. Decrease the amount of range of motion performed if tightness occurs. C. Perform range-of-motion exercises to the affected side once per day. D. Avoid repetitive movements during exercise.

Correct Answer is A

Explanation

A) Initiate frequent, short periods of exercise throughout the day: Frequent, short periods of exercise are beneficial for a client with left-sided hemiplegia. Regular movement helps maintain joint flexibility, muscle strength, and overall functional ability. This approach can prevent complications such as contractures and muscle atrophy.

B) Decrease the amount of range of motion performed if tightness occurs: If tightness occurs, rather than decreasing range of motion, it is important to address it through appropriate stretching and adjustments in exercise technique. Reducing range of motion could lead to further loss of mobility and function.

C) Perform range-of-motion exercises to the affected side once per day: Performing range-of-motion exercises only once per day is generally insufficient. To maintain or improve mobility and prevent contractures, range-of-motion exercises should be performed multiple times throughout the day, as directed by the care plan.

D) Avoid repetitive movements during exercise: Repetitive movements are not necessarily harmful and can be beneficial for improving motor function and muscle coordination. However, it is important to balance repetitive exercises with variety and adjust based on the client’s condition and tolerance.

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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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