# Review the outpatient infection-control timeline and determine the immediate response when measles becomes suspected. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=394842&lang=en > language: en > subject: Standard/Transmission-Based Precautions/Surgical Asepsis > category: SIPC ## Question Review the outpatient infection-control timeline and determine the immediate response when measles becomes suspected. | Time | Data | | --- | --- | | Check-in | Temperature 40.0 C with cough, coryza, and conjunctivitis. A community measles outbreak is active. The client sits in the common waiting area. | | +10 minutes | Nurse observes small white buccal lesions and a maculopapular rash beginning at the hairline. | | +20 minutes | Laboratory confirmation is not yet available. Several patients and staff have shared the waiting-room airspace. | Q1. How should the nurse interpret the trend? A routine viral illness that requires Standard Precautions only A contact-transmitted infection that can remain in the waiting room Suspected measles with an urgent airborne-transmission risk Q2. What should the nurse do immediately? Wait for laboratory confirmation before changing precautions Place source control on the client, move the client to an AIIR, use a fit-tested N95 or higher respirator, and notify infection prevention Use a surgical mask for staff and continue care in the common waiting area Q3. Which action addresses the shared waiting-room exposure? Reopen the area immediately after wiping chairs Notify only staff who are not vaccinated Prevent new exposure and begin airspace and contact management with infection prevention and public health ## Explanation High fever, cough, coryza, conjunctivitis, Koplik spots, and a spreading maculopapular rash during a measles outbreak create a strong suspicion for measles. The nurse should immediately place well-fitting source control on the client if tolerated, move the client directly to an airborne infection isolation room or the safest available private room with the door closed, and use Standard and Airborne Precautions. Staff entering should wear respiratory protection at least as protective as a fit-tested NIOSH-approved N95. Infection prevention and the health department should be notified according to policy. Shared airspace may remain an exposure concern for up to 2 hours, so exposure management should begin without waiting for laboratory confirmation. ## In-depth explanation Trend to recognize The three C symptoms, high fever, Koplik spots, and rash during an outbreak make measles an infection-control emergency before testing returns. Immediate sequence Identify, place source control, isolate in an AIIR, use a fit-tested N95 or higher respirator, and inform infection prevention and public health. Airspace rule Measles can remain infectious in shared air for up to 2 hours. Stop additional exposure and begin identifying potentially exposed persons according to the facility and health-department plan. Why the alternatives fail Droplet precautions alone are insufficient. Waiting in a common area for the rash or laboratory result increases exposure. Vaccination history does not replace recommended respiratory protection for healthcare personnel entering the room. Source 1CDC Measles Infection Prevention and Control in Healthcare Settings 22026 NCLEX-RN Test Plan ## Clinical scenario Outpatient clinic An adult with fever and respiratory symptoms checks in during a community measles outbreak. 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Always follow current clinical guidelines and your institution’s protocols._