While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device.
Which of the following actions should the nurse take first?

This is because rubella is a highly contagious viral infection that can cause serious harm to the developing fetus if the pregnant person gets infected. Rubella can cause congenital rubella syndrome, which can result in hearing and vision loss, heart defects and other serious conditions in newborns.

Choice A is wrong because aspirin should not be given to children or adolescents with viral infections, as it can cause Reye’s syndrome, a rare but potentially fatal condition that affects the liver and brain.

Choice C is wrong because rubella does not require airborne precautions, which are used for diseases that can spread through very small droplets that can remain in the air for long periods of time, such as tuberculosis or measles. Rubella spreads through direct contact with saliva or mucus of an infected person, or through respiratory droplets from coughing or sneezing.

Therefore, standard and droplet precautions are sufficient to prevent transmission. Choice D is wrong because Koplik spots are a characteristic sign of measles, not rubella.

Koplik spots are small white spots that appear on the inside of the cheeks before the measles rash develops. Rubella causes a pink or red rash that usually starts on the face and moves down the body.

Normal ranges for rubella antibody tests are:

• IgM: Negative or less than 0.9 IU/mL
• IgG: Negative or less than 10 IU/mL

A positive IgM result indicates a recent or current infection, while a positive IgG result indicates a past infection or immunity from vaccination.

The correct answer is choice D: A client who is taking warfarin and has an INR of 1.8.

Choice A rationale:

A Mantoux test with an induration after 48 hours can be a normal reaction, especially if the induration is within the expected size range for a positive result, depending on the individual’s risk factors and history. It does not necessarily require follow-up care unless the induration is significantly large or there are other concerning symptoms.

Choice B rationale:

A client scheduled for a colonoscopy and taking sodium phosphate does not typically require follow-up care for the sodium phosphate intake itself. Sodium phosphate is commonly used as a bowel prep medication to clear the intestines prior to the procedure.

Choice C rationale:

A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L), so a client taking bumetanide with this potassium level would not typically require follow-up care for the potassium level alone.

Choice D rationale:

A client taking warfarin with an INR of 1.8 requires follow-up care because the therapeutic range for warfarin is typically between 2.0 and 3.0 for most indications. An INR of 1.8 may indicate that the blood is not “thin” enough, increasing the risk of thrombotic events, and the warfarin dose may need adjustment.