A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?

Choice A rationale:

Placing the client on airborne precautions for measles is the appropriate action. Measles is highly contagious and spreads through respiratory droplets. Airborne precautions, including wearing a mask, are essential to prevent the transmission of the virus to others. This action is in line with infection control protocols and ensures the safety of both healthcare providers and other patients.

Choice B rationale:

Having the client wear a mask for transport to radiology is a necessary precaution to prevent the spread of measles to others in the healthcare facility. It helps contain respiratory droplets and reduces the risk of transmission. This action aligns with infection control guidelines and is appropriate in this context.

Choice C rationale:

Wearing an N95 respirator when caring for a client with measles is necessary to protect healthcare providers from inhaling infectious particles. Measles is highly contagious, and airborne precautions, including the use of appropriate respiratory protection, are crucial. This action demonstrates the nurse's understanding of infection control measures.

Choice D rationale:

Ensuring the client's room maintains a positive airflow is wrong in anairborne infection isolation room. Negativeairflow helps prevent the contaminated air from flowing out of the room and spreading the infection to other areas of the healthcare facility. This action is consistent with the recommended infection control practices for airborne diseases.

- A. Incorrect. The lithotomy position is not appropriate for this procedure, as it can cause discomfort and embarrassment to the client. The nurse should place the client in a left lateral Sims' position with the right knee flexed for better access to the rectum and to reduce pressure on the abdominal organs.

- B. Incorrect. The nurse should avoid eliciting a vagal response, as it can cause bradycardia, hypotension, and syncope in some clients. The nurse should monitor the client's vital signs and stop the procedure if signs of vagal stimulation occur.

- C. Incorrect. Oral bisacodyl is a stimulant laxative that can cause abdominal cramping, diarrhea, and electrolyte imbalance. It is not indicated for fecal impaction, as it can worsen the condition by increasing the bulk and hardness of the stool. The nurse should administer an enema or a stool softener before attempting digital evacuation.

- D. Correct. The nurse should insert a lubricated gloved finger and advance along the rectal wall, breaking up the stool and removing it in small pieces. The nurse should use gentle pressure and avoid injuring the rectal mucosa. The nurse should also explain the procedure to the client and obtain informed consent before performing it.