A nurse is assisting with planning care for a client who was admitted for reports of severe coughing, night sweats, and blood in the sputum. Which of the following precautions should the nurse take?

Place the client in a negative-pressure airflow room.

Wear a surgical mask when entering the client's room.

Have a container for soiled linens outside the client's door.

Remain within 91.4 cm (3 ft) of the client.

Answer and Explanation

The Correct Answer is A

A. Place the client in a negative-pressure airflow room: This is correct as these symptoms are indicative of tuberculosis (TB), which requires airborne precautions. A negative-pressure room helps to prevent the spread of airborne pathogens.
B. Wear a surgical mask when entering the client's room: This is incorrect because a surgical mask does not provide adequate protection against airborne particles; an N95 respirator is necessary for airborne precautions.
C. Have a container for soiled linens outside the client's door: This is incorrect as soiled linens should be handled and disposed of within the room under appropriate infection control protocols, not just placed outside.
D. Remain within 91.4 cm (3 ft) of the client: This is incorrect as maintaining this distance does not prevent the spread of airborne diseases. Proper airborne precautions, including the use of personal protective equipment, are necessary.

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Correct Answer is A

Explanation

A. Increase the IV flow rate: This is correct as the client’s low blood pressure could indicate hypovolemia. Increasing the IV flow rate can help improve blood volume and blood pressure, addressing a potential cause of hypotension.
B. Cover the client with a warm blanket: While this could help if the client is hypothermic, it does not address the immediate issue of low blood pressure.
C. Compare the reading to the preoperative value: While this can provide context, it does not directly address the current low blood pressure situation.
D. Reassure the client: Reassuring the client is important but does not address the urgent issue of low blood pressure.

A. "I will increase vitamin C intake by drinking orange juice." B. "I will lie down for 30 minutes after each meal." C. "I will eat six small meals each day." D. "I will sleep flat on my back at night."

Correct Answer is C

Explanation

A. "I will increase vitamin C intake by drinking orange juice": This is incorrect because citrus juices like orange juice can exacerbate GERD symptoms by increasing acid production.
B. "I will lie down for 30 minutes after each meal": This is incorrect as lying down after eating can increase the risk of acid reflux. Clients should remain upright for at least 2-3 hours after eating.
C. "I will eat six small meals each day": This is correct because eating smaller, more frequent meals can help reduce the frequency of GERD symptoms by decreasing stomach pressure and acid production.
D. "I will sleep flat on my back at night": This is incorrect as sleeping flat can worsen GERD symptoms. Elevating the head of the bed can help prevent acid reflux during sleep.

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A nurse is assisting with planning care for a client who was admitted for reports of severe coughing, night sweats, and blood in the sputum. Which of the following precautions should the nurse take?

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