A charge nurse is observing a newly licensed nurse who is caring for a client who has pulmonary tuberculosis. The charge nurse should expect the newly licensed nurse to take which of the following actions?
Place the client on droplet precautions.
Place the client in a room with positive-pressure airflow.
Wear a surgical mask when taking the client out of the room.
Wear an N95 respirator mask when in the client's room.
The Correct Answer is D
Answer is: Wear an N95 respirator mask when in the client’s room.
Explanation: Pulmonary tuberculosis (TB) is a contagious disease caused by bacteria that can spread through the air. The most common way of transmission is through respiratory droplets that are expelled when a person with active TB coughs, sneezes, or speaks1. Therefore, the charge nurse should expect the newly licensed nurse to take precautions to protect themselves and the client from exposure to TB. One of these precautions is to wear an N95 respirator mask when in the client’s room2. An N95 respirator mask is a type of personal protective equipment (PPE) that filters out at least 95% of airborne particles, including bacteria and viruses3. It can prevent the nurse from inhaling or spreading TB to others.
The other options are incorrect because:
Place the client on droplet precautions: Droplet precautions are not enough to prevent transmission of TB, as they only protect against respiratory droplets that are less than 5 micrometers in diameter1. However, TB bacteria can be found in larger droplets that can travel farther and infect people who are not in direct contact with the source1.
Place the client in a room with positive-pressure airflow: Positive-pressure airflow is not effective against TB, as it does not reduce the concentration of airborne particles or prevent them from escaping through cracks and gaps in doors and windows. Moreover, positive-pressure airflow can create negative pressure in other areas of the facility, which can increase the risk of cross-contamination.
Wear a surgical mask when taking the client out of the room: A surgical mask is not sufficient to protect against TB, as it only filters out particles that are larger than 5 micrometers in diameter3. It also does not fit properly on the face and may allow some particles to pass through3.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Child Protective Services would not be the appropriate agency to refer the guardian of the newborn who requires apnea monitoring at home. Child Protective Services deals with child abuse, neglect, and welfare concerns, which are not related to the specific medical needs of the newborn.
Choice B rationale:
Public Health is the correct choice. Public Health agencies are responsible for promoting and protecting the health of the community. They often provide services such as education, vaccinations, and resources for newborn care. Referring the guardian to Public Health can ensure that they receive appropriate guidance on how to manage the newborn's apnea monitoring needs at home and any other relevant health-related information.
Choice C rationale:
Home Health is not the most suitable agency in this context. Home Health agencies generally provide healthcare services directly in patients' homes, often for individuals who require medical assistance or supervision due to illnesses or post-surgical care. However, for a newborn requiring apnea monitoring, the focus is more on education and support rather than direct medical care.
Choice D rationale:
Women, Infants, and Children (WIC) is not the appropriate agency for referring the guardian of the newborn needing apnea monitoring. WIC is a program that provides supplemental nutrition and support to pregnant women, breastfeeding mothers, and young children. While it is important for the overall health of the newborn, it is not directly related to apnea monitoring or home care.
Correct Answer is D
Explanation
Choice A rationale:
A client who has a penetrating head injury and a respiratory rate of 4/min requires immediate attention due to the critical nature of the head injury and the dangerously low respiratory rate. However, in an emergency situation like this, the priority would be a condition that could be rapidly fatal if not addressed promptly.
Choice B rationale:
A client with a comminuted fracture of the femur has a serious injury that requires assessment and treatment, but it is not an immediately life-threatening condition. It falls lower in the priority compared to conditions that directly impact respiratory and cardiovascular function.
Choice C rationale:
A client with a 15.2-cm laceration to the scalp with clotted blood visible also requires attention, but it is not as time-sensitive as a life-threatening condition. Controlling bleeding and cleaning the wound can be addressed after addressing more critical cases.
Choice D rationale:
Correct. A client with a sucking chest wound has a high risk of tension pneumothorax, a condition where air accumulates in the pleural space, leading to lung collapse and compromised circulation. This condition can be rapidly fatal. Immediate intervention is required to seal the wound and prevent further air from entering the pleural space.
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