A nurse is assisting with planning interventions for an influenza outbreak in a long-term care facility. Which of the following interventions should the nurse include in the plan?
Provide prophylactic antibiotics for clients who have been exposed to influenza.
Assign health care personnel to non-direct care activities for 24 hours after developing influenza symptoms.
Place restrictions on visitation.
Implement airborne precautions for clients who have influenza.
The Correct Answer is C
A. Provide prophylactic antibiotics for clients who have been exposed to influenza: Antibiotics are not effective against viral infections like influenza. Antiviral medications may be used for prophylaxis in exposed individuals.
B. Assign health care personnel to non-direct care activities for 24 hr after developing influenza symptoms: Healthcare personnel should not provide care while symptomatic. The recommended restriction period is typically longer than 24 hours.
C. Place restrictions on visitation. During an influenza outbreak, limiting visitation can reduce the spread of infection, especially in vulnerable populations like those in long-term care facilities.
D. Implement airborne precautions for clients who have influenza: Influenza is spread through droplets, not airborne particles. Droplet precautions are appropriate.
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Correct Answer is A
Explanation
A. Maintain the drainage container below the level of the client's chest. Keeping the drainage container below the level of the client's chest allows gravity to assist in draining fluid or air from the pleural space and prevents backflow into the chest.
B. Add tap water as needed to the suction control chamber: This is incorrect; sterile water should be used, not tap water, to prevent contamination.
C. Clamp the chest tubes if it becomes disconnected: This is not recommended as clamping can create a tension pneumothorax. Instead, the nurse should use a sterile gauze to cover the site and notify the provider.
D. Empty the collection container every shift: The collection container should be emptied as needed, not on a set schedule, to ensure proper function and accurate measurement of drainage.
Correct Answer is D
Explanation
A. Decreasing respiratory rate: This is not expected; respiratory rate may increase as the body attempts to compensate for reduced oxygenation.
B. Facial flushing: This is not a common symptom of atelectasis and may indicate other issues such as anxiety or fever.
C. Dry cough: While a cough may be present, it is more likely to be productive due to retained secretions.
D. Increasing dyspnea: Atelectasis often leads to decreased lung volume, which can cause increasing dyspnea as the lung tissue collapses.