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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
The client's fingers are cool to the touch is correct. Coolness of the fingers within a short time after a cast application can indicate compromised circulation or potential compartment syndrome, which requires urgent attention to prevent tissue damage or loss of function. It suggests impaired blood flow to the fingers, which is a serious concern requiring immediate evaluation by the provider.
Choice B Reason:
The client reports severe itching under the cast is incorrect. While itching can be uncomfortable, it might not pose an immediate threat. Itching can commonly occur as the skin heals and can be managed through non-invasive means.
Choice C Reason:
The client's capillary refill is 3 seconds is incorrect. A capillary refill of 3 seconds is slightly prolonged but doesn't typically indicates an immediate emergency. However, if this finding worsens or if combined with other concerning symptoms, it might warrant further assessment.
Choice D Reason:
The client reports increased pain at the area of the fracture is incorrect. Increased pain after a cast application can be expected initially, especially within 2 hours of the procedure. However, persistent or severe pain could indicate issues like poor alignment, swelling, or other complications. While it's important to address pain, it might not require immediate reporting unless accompanied by other concerning symptoms.
Correct Answer is B, A, C, E, D
Explanation
Clamp the catheter tubing distal to the sampling port for 15 min. By clamping the tubing distal to the sampling port, it allows urine to accumulate in the tubing, ensuring that the urine specimen obtained is fresh and not from the stagnant urine that has been sitting in the tubing.
Wipe the sample port with an alcohol wipe and let the alcohol dry. Cleaning the sampling port with an alcohol wipe helps reduce the risk of introducing contaminants into the sample during collection, ensuring a more sterile procedure.
Attach a sterile needleless syringe to the sample port and aspirate the specimen. Using a sterile syringe prevents contamination and allows for the collection of a clean urine sample directly from the catheter tubing, maintaining the sterility of the specimen.
Empty the urine into a sterile container labeled with the client identifiers. Transferring the collected urine into a sterile container labeled with the client's identifiers ensures proper identification and handling of the specimen for laboratory analysis.
Document in the client's electronic medical record that the specimen was sent to the laboratory. Documenting in the client's medical record ensures that there is a clear record of the specimen collection, its handling, and its dispatch to the laboratory for analysis, maintaining proper documentation and continuity of care.
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