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 C

Explanation

Choice A Reason:

"You will not become fatigued when you use assistive devices. “This statement might provide an unrealistic expectation. While assistive devices can help, they might still require physical effort and could potentially cause fatigue, especially during initial use or extended periods.

Choice B Reason:

"Plan to hire a home care aid to perform all of your ADLs." This statement is not appropriate.

While home care assistance can be beneficial, aiming to have someone perform all ADLs might limit the client's independence and ability to regain skills. The goal is often to support the client in performing ADLs independently whenever possible.

Choice C Reason:

"Install grab bars in your shower to assist with your balance." This statement is true. Installing grab bars in the shower can significantly enhance safety and stability during activities like showering, reducing the risk of falls for someone who might experience balance or mobility challenges following a CVA.

Choice D Reason:

"Place a towel in the shower to prevent slipping." This statement is inappropriate. While placing a towel might offer some traction, it might not provide sufficient stability or support, especially for someone with balance issues post-CVA. Grab bars offer more reliable support to prevent falls in the shower.

A. Maintain skin integrity over the blisters B. Apply ice to the larger blisters. C. Administer (buprofen for pain. D. Run cool water over the affected area. E. Allow the affected area to remain open to air.

Correct Answer is ["A","C","D"]

Explanation

Choice A Reason:

Maintaining skin integrity over the blisters is correct. Blisters form as a protective mechanism for the skin underneath. Popping or breaking blisters increases the risk of infection as it exposes the raw skin to bacteria and other contaminants.

Choice B Reason:

Applying ice to the larger blisters is incorrect.

Reason: Applying ice directly to a burn, especially to blisters, can further damage the skin and exacerbate the injury. Ice can cause additional skin damage and can potentially increase pain and delay healing.

Choice C Reason:

Administering ibuprofen for pain is correct. Ibuprofen is an effective over-the-counter pain reliever that can help manage the discomfort caused by a minor burn. It also has anti-inflammatory properties that can reduce swelling associated with burns.

Choice D Reason:

Running cool water over the affected area is correct. Running cool (not cold) water over the burn helps to cool down the burned area, soothes the pain, and helps prevent further damage to the skin. It's recommended to run water over the burn for around 10-15 minutes to effectively cool the area.

Choice E Reason:

Allowing the affected area to remain open to air is incorrect. Keeping a minor burn uncovered can increase the risk of infection as it exposes the burn to external contaminants. Covering the burn with a sterile, non-stick dressing can protect it from further damage and reduce the risk of infection.

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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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