A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?

Have the client wear a surgical mask during transport.

Wear an N95 mask while providing care to the client.

Administer an influenza immunization to the client.

Place the client in a negative airflow room.

Answer and Explanation

Correct Answer : A

a. Have the client wear a surgical mask during transport. This is the appropriate intervention to prevent the spread of the influenza virus when the client needs to be transported within the healthcare facility. Influenza is primarily spread through respiratory droplets, so wearing a surgical mask helps to contain these droplets.
b. Wear an N95 mask while providing care to the client. An N95 mask is generally not required for influenza. Standard precautions, including wearing a surgical mask when within close proximity to the client, are usually sufficient.
c. Administer an influenza immunization to the client. It is not appropriate to administer the influenza vaccine to a client who is already infected with the influenza virus.
d. Place the client in a negative airflow room. Negative airflow rooms are typically reserved for airborne diseases such as tuberculosis. Influenza, which spreads via droplets, does not require this level of isolation.

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Correct Answer is D

Explanation

Choice A Reason:

Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL) is incorrect. Bilirubin levels within the normal range typically indicate normal liver function. The value of 1.0 mg/dL falls within the expected range, so it doesn't raise immediate concerns regarding the need for a liver biopsy.

Choice B Reason:

Aspartate aminotransferase 34 units/L (0 to 34 units/L) is incorrect. Aspartate aminotransferase (AST) is an enzyme found in various tissues, including the liver, heart, muscles, and red blood cells. While a value of 34 units/L is at the upper limit of the normal range, it's still within the expected range and doesn't typically prompt immediate concern for the need for a biopsy.

Choice C Reason:

Ammonia 55 mcg/dL (10 to 80 mcg/dL ) is incorrect. Ammonia levels can rise in cases of liver dysfunction. The level of 55 mcg/dL falls within the reference range, indicating normal or near-normal ammonia levels, which doesn't usually necessitate an urgent liver biopsy.

Choice D Reason:

Platelets 60,000/mm3 (150,000 to 400,000/mm3) is correct. Platelets are crucial for blood clotting. A significantly low platelet count, such as 60,000/mm3, termed thrombocytopenia, can indicate compromised clotting ability, which might pose a risk of bleeding during or after a liver biopsy. In the context of a liver biopsy, a low platelet count warrants attention and consideration before proceeding with the procedure to prevent excessive bleeding or complications.

A. Cleanse the site with an antiseptic swab. B. Allow the site to dry. C. Pierce the puncture site quickly. D. Squeeze the site gently to obtain a blood droplet. E. Apply blood to the test strip.

Correct Answer is A, B, C, D, E

Explanation

A. Cleanse the site with an antiseptic swab: Begin by cleaning the puncture site to reduce the risk of infection. B. Allow the site to dry: Let the antiseptic dry completely to prevent contamination or dilution of the blood sample. C. Pierce the puncture site quickly: Use a lancet to pierce the skin in one swift motion to minimize discomfort. D. Squeeze the site gently to obtain a blood droplet: Gently apply pressure to the site to encourage a droplet of blood to form. E. Apply blood to the test strip: Once the blood droplet forms, apply it to the test strip for analysis.

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A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is A, B, C, D, E

Explanation

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