A nurse is planning care for a client who has disseminated herpes zoster (shingles). Which of the following interventions should the nurse include?

Place the client in a room with negative airflow.

Remove isolation gown after leaving the client's room.

Apply ketoconazole to the lesions three times per day.

Provide the client with eye protection for ultraviolet B light therapy.

Answer and Explanation

The Correct Answer is A

Answer: A

Rationale:

A) Place the client in a room with negative airflow: Disseminated herpes zoster (shingles) requires airborne precautions because the virus can become aerosolized. A room with negative airflow helps prevent the spread of the virus to other areas, protecting healthcare workers and other patients from infection.

B) Remove isolation gown after leaving the client's room: Isolation gowns should be removed before leaving the client's room to prevent the spread of contaminants to other areas. This intervention is important for infection control but is not specific to the requirement for negative airflow in cases of disseminated herpes zoster.

C) Apply ketoconazole to the lesions three times per day: Ketoconazole is an antifungal medication and is not used for treating herpes zoster, which is caused by a viral infection. Antiviral medications, such as acyclovir, are appropriate for treating herpes zoster lesions.

D) Provide the client with eye protection for ultraviolet B light therapy: Eye protection is necessary during UVB light therapy to protect the eyes, but UVB light therapy is not a standard treatment for disseminated herpes zoster. The priority intervention is to prevent the spread of the infection by using a negative airflow room.

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Correct Answer is A

Explanation

Choice A rationale:

A decrease in NG tube drainage indicates that the client's stomach contents are not being aspirated excessively, which suggests that the IV fluids are effectively maintaining fluid volume balance. This finding is positive because it shows that the client is retaining the fluids they need, and it may also indicate improved gastrointestinal function and decreased risk of dehydration.

Choice B rationale:

The potassium level of 3.3 mEq/L (milliequivalents per liter) is low. The normal range for potassium is typically between 3.5 to 5.0 mEq/L. Hypokalemia (low potassium) can result from various factors and may cause muscle weakness, cardiac arrhythmias, and other complications. It is not a finding that indicates the effectiveness of fluid volume balance therapy.

Choice C rationale:

An increased heart rate may suggest that the client is experiencing fluid volume deficit or other physiological stress. It is not a finding that indicates the effectiveness of fluid volume balance therapy.

Choice D rationale:

A hematocrit level of 46% is within the normal range for adult males (typically around 38.8% to 50%) and indicates the proportion of red blood cells in the blood. While it can provide information about blood viscosity and hydration status, it does not directly indicate the effectiveness of fluid volume balance therapy.

A. Provide teaching about the surgical procedure for the client. B. Instruct the client's spouse to sign the consent form. C. Read the consent form to the client using words the client will understand. D. Contact the provider who will be performing the procedure.

Correct Answer is D

Explanation

Answer: D. Contact the provider who will be performing the procedure.

Rationale:

A) Provide teaching about the surgical procedure for the client:

While nurses play an essential role in patient education, it is the responsibility of the healthcare provider performing the procedure to ensure the patient fully understands the details, risks, and benefits. Nurses can clarify information but should not provide the initial comprehensive explanation of the procedure.

B) Instruct the client's spouse to sign the consent form:

The client is the one who needs to provide informed consent, not the spouse, unless the client is legally unable to do so. In such cases, legal documentation, such as a power of attorney, is required. Instructing the spouse to sign without proper authorization is inappropriate and potentially legally problematic.

C) Read the consent form to the client using words the client will understand:

While simplifying the language of the consent form can help, it is not sufficient if the client does not fully understand the procedure. Full understanding requires a detailed discussion about the procedure, risks, benefits, and alternatives, which should be done by the provider performing the procedure.

D) Contact the provider who will be performing the procedure:

The provider performing the procedure has the responsibility to ensure the client understands all aspects of the surgery. Contacting the provider to provide a thorough explanation ensures that the client receives accurate and complete information, allowing for truly informed consent.

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A nurse is planning care for a client who has disseminated herpes zoster (shingles). Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an NG tube to suction and is receiving IV fluids to maintain fluid volume balance. Which of the following findings should indicate to the nurse that this therapy is effective?

Correct Answer is A

Explanation

A nurse is assessing a client's understanding of a surgical procedure prior to witnessing their signature on the informed consent form. The nurse determines that the client does not understand what the procedure will involve. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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