The nurse is caring for four clients:

• Client A, who has emphysema and whose oxygen saturation is 94% on room air;
• Client B, with a postoperative hemoglobin of 8.2 mg/dL (82 g/L);
• Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L);
• Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm3 (14 x 109/L).

Which intervention should the nurse implement?Reference Range:

• Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]
• Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
• White Blood Cell [5,000 to 10,000/mm3 (5 to 10 x 109/L)]

Rationale

A. Herpes simplex virus type II (HSV-II) primarily spreads through direct contact with the lesions and is not airborne. Airborne precautions and negative airflow rooms are not necessary for this condition.

B. Scarlet fever is caused by Group A Streptococcus bacteria and typically spreads through respiratory droplets. However, scarlet fever itself does not require airborne precautions. If complicated with pneumonia, respiratory droplets could potentially spread the infection, but specific airborne precautions are generally not required unless there are other pathogens involved that require it.

C. Scabies is caused by the Sarcoptes scabiei mite and spreads through direct skin-to-skin contact. It does not require airborne precautions or negative airflow rooms.

D. Apositive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) suggest tuberculosis (TB) infection. TB is spread through airborne droplets (e.g., coughing, sneezing), and therefore, requires airborne precautions including negative airflow rooms to prevent transmission to others.A

Rationale

A. While ensuring the room is secure and providing one-on-one observation are also important, the immediate concern after administering haloperidol is the potential for these side effects.

B. Continuous observation is crucial to monitor the client's behavior, mood, and safety while in seclusion. This allows the nurse to intervene promptly. However, monitoring should be specific

C. Seclusion is not intended as a punishment but as a therapeutic intervention to protect the client and others from harm during acute psychiatric episodes. The decision to release the client should be based on clinical assessment

D. Haloperidol is an antipsychotic medication that can cause extrapyramidal symptoms (EPS), including dystonia (muscle spasms). Monitoring for EPS is essential after administering haloperidol to ensure early detection and treatment, which may involve administering anticholinergic medications if EPS occurs.