A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take?
Restrict the client's visitors to the immediate family.
Assign the client to a negative pressure airflow room.
Discard personal protective equipment outside the client's room.
Have the client wear a HEPA mask during transportation throughout the facility.
The Correct Answer is B
A. Restrict the client's visitors to the immediate family: While tuberculosis is a communicable disease, restricting visitors to the immediate family is not a standard precautionary measure. Visitors should be educated about infection control measures and individuals with active tuberculosis
may need to wear masks in certain situations.
B. Assign the client to a negative pressure airflow room: Correct. Clients with active tuberculosis should be placed in a negative pressure airflow room to prevent the spread of infectious airborne particles to other areas of the facility. Negative pressure ensures that air from the room does not flow to other parts of the facility.
C. Discard personal protective equipment outside the client's room: Personal protective equipment (PPE) should be removed and discarded according to facility policy, which often includes removing PPE inside the client's room and properly disposing of it afterward. The nurse should follow standard precautions for infection control.
D. Have the client wear a HEPA mask during transportation throughout the facility: While wearing a HEPA mask may be necessary for clients with tuberculosis, it is not related to the initial admission process. Clients with active tuberculosis may be asked to wear a HEPA mask during transportation when they need to leave their negative pressure room.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability.
B: Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent.
C: Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches.
D: Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.
Correct Answer is C
Explanation
A: While explaining the negative consequences of refusal is important, it may not change the client's decision, and respect for the client's autonomy must be upheld.
B: Discussing the treatment with the client's partner without the client's consent may breach patient confidentiality and privacy.
C: Correct. The nurse should document the client's refusal of the medical treatment in the client's medical record. This documentation is essential for legal and ethical purposes and to ensure that the refusal is adequately communicated to the healthcare team.
D: Trying to convince the client to undergo the treatment is not appropriate and may violate the principle of informed consent. The client has the right to refuse treatment after being adequately informed of the risks and benefits.
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