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:

Administer meperidine IM is incorrect. Reason why it's not the answer: Meperidine (Demerol) is not recommended in cases of malignant hyperthermia. It can potentially exacerbate the situation by further increasing muscle rigidity and potentially contributing to the hypermetabolic state. Meperidine can trigger additional release of calcium from the sarcoplasmic reticulum in muscles, worsening the symptoms.

Choice B Reason:

Instill a warm enema solution is incorrect. Reason why it's not the answer: Introducing warm solutions can exacerbate the client's condition by further increasing body temperature. Malignant hyperthermia is characterized by a dangerous increase in body temperature, and adding heat through an enema would only make the situation worse.

Choice C Reason:

Applying a cooling blanket is recommendable. Reason why it's the answer: A cooling blanket is a recommended intervention for managing malignant hyperthermia. Lowering the body temperature is crucial in preventing further complications associated with the high fever. Cooling blankets help dissipate heat from the body, aiding in rapidly reducing the dangerously elevated temperature associated with malignant hyperthermia.

Choice D Reason:

Ventilate client with 50% oxygen is incorrect. Reason why it's not the answer: While providing oxygen support might be necessary as part of managing the overall condition, ventilating with 50% oxygen specifically may not directly address the core issue of rapidly cooling the body during a malignant hyperthermia crisis. Ventilation may be required, but the immediate concern is to cool the body to prevent complications arising from the elevated body temperature.

A. Maintain skin integrity over the blisters. B. Apply ice to the larger blisters. C. Administer ibuprofen 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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Correct Answer is C

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

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