A nurse is assisting with the admission of a client who has tuberculosis with a productive cough.
Which type of isolation precautions should the nurse initiate for the client?

Airborne.

Protective.

Droplet.

Contact.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Airborne precautions should be initiated for clients with tuberculosis (TB) who have a productive cough. TB is transmitted through the airborne route when an infected individual coughs, sneezes, or talks, releasing infectious droplets into the air. Airborne precautions include the use of negative-pressure isolation rooms and N95 respirators for healthcare workers to prevent the spread of TB.

Choice B rationale:

Protective precautions are not typically used for clients with TB. Protective precautions are more commonly employed for clients with compromised immune systems to protect them from infection.

Choice C rationale:

Droplet precautions are not sufficient for clients with TB because TB is primarily transmitted via airborne particles, not droplets. Droplet precautions are used for diseases like influenza or meningitis, which are transmitted through larger respiratory droplets.

Choice D rationale:

Contact precautions are not appropriate for clients with TB because TB is primarily transmitted through the airborne route. Contact precautions are typically used for diseases that are transmitted through direct contact with the client or contaminated surfaces.

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Correct Answer is ["A","B","C"]

Explanation

Answer is: A, B, and C.Respiratory rate, oxygen saturation level, and heart rate are the three findings that require immediate follow-up. These findings indicate that the client is experiencing respiratory distress and possible complications of pneumonia, such as sepsis and cardiac arrhythmia. The client needs prompt intervention to improve oxygenation, stabilize the heart rhythm, and treat the infection.

Statement D is wrong because the chronic health condition of the client (Parkinson’s disease) is not an acute problem that needs immediate attention. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease.
Statement E is wrong because the current level of consciousness of the client (alert and oriented to self) is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation.
Statement F is wrong because the tremors of the client are likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures.

Normal ranges for the vital signs and arterial blood gas are as follows:

Correct answer is: A, B, and C.

Choice A rationale: Respiratory rate is 28 breaths per minute and labored. This is above the normal range of 12 to 20 breaths per minute and indicates that the client is experiencing respiratory distress. Respiratory distress can lead to hypoxia, tissue damage, and organ failure. Therefore, this finding requires immediate follow-up to improve the client’s oxygenation and ventilation.

Choice B rationale: Oxygen saturation level is 88% on room air. This is below the normal range of 95% to 100% and indicates that the client is hypoxemic. Hypoxemia can result from pneumonia, which causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. Hypoxemia can also cause dysrhythmias, confusion, and cyanosis. Therefore, this finding requires immediate follow-up to administer supplemental oxygen and monitor the client’s response.

Choice C rationale: Heart rate is 110 beats per minute and irregular. This is above the normal range of 60 to 100 beats per minute and indicates that the client has tachycardia and atrial fibrillation. Tachycardia can result from hypoxia, fever, infection, dehydration, or anxiety. Atrial fibrillation is a type of cardiac arrhythmia that causes irregular and rapid contractions of the atria, reducing the cardiac output and increasing the risk of thromboembolism. Therefore, this finding requires immediate follow-up to identify and treat the underlying cause, stabilize the heart rhythm, and prevent complications.

Choice D rationale: Chronic health condition is Parkinson’s disease. This is not an acute problem that requires immediate follow-up. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease, as they can affect the client’s mobility, safety, and quality of life.

Choice E rationale: Current level of consciousness is alert and oriented to self. This is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation, as they can result from hypoxia, infection, or medication side effects.

Choice F rationale: Tremors are in both hands. This is likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures, such as warm blankets, massage, or relaxation techniques.

A. "I will carry my baby to the nursery.” B. "I can take my baby to the lobby to visit family.” C. "I will have an identification band that matches the one my baby wears.” D. "I can remove my security band to give it to a family member.”

Correct Answer is C

Explanation

Choice A rationale:

Carrying the baby to the nursery may not align with facility security measures. Typically, hospitals have strict protocols for baby transport within the facility, including the use of identification bands.

Choice B rationale:

Taking the baby to the lobby to visit family may also not be in line with security measures. Visitors should typically come to the designated patient areas rather than taking the baby to the lobby.

Choice C rationale:

Having an identification band that matches the one the baby wears is the correct understanding of facility security measures. This ensures proper identification of the baby and helps prevent infant abduction or mix-ups.

Choice D rationale:

Removing the security band to give it to a family member is not in line with security measures. The baby's identification band should remain intact at all times to ensure proper identification and security.

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A nurse is assisting with the admission of a client who has tuberculosis with a productive cough.Which type of isolation precautions should the nurse initiate for the client?

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A nurse is assisting with the admission of a client who has tuberculosis with a productive cough.
Which type of isolation precautions should the nurse initiate for the client?