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 D

Explanation

Choice A rationale:

Insomnia is not typically associated with increased intracranial pressure (ICP) Instead, infants with increased ICP may exhibit signs of altered consciousness, lethargy, or increased sleepiness.

Choice B rationale:

A low-pitched cry is not a specific manifestation of increased ICP. Increased ICP in infants may cause high-pitched crying due to discomfort or irritability.

Choice C rationale:

A positive Babinski reflex is not a typical manifestation of increased ICP in infants. Instead, increased ICP may result in neurological signs such as altered level of consciousness, irritability, vomiting, and changes in vital signs.

Choice D rationale:

Bulging fontanel is the correct manifestation to expect in an infant with increased ICP. The fontanel may become tense and bulging due to increased pressure within the skull. This is a concerning sign and should be promptly reported for further evaluation and intervention.

A. Determine the client's ability to use the call light. B. Create a schedule with an assistive personnel to do hourly rounding for the client. C. Move the bedside table with the client's personal items close to the bed. D. Apply rubber-soled slippers before ambulation.

Correct Answer is A

Explanation

Choice A rationale:

"Determine the client's ability to use the call light." - This is the correct answer. Assessing the client's ability to use the call light is the first step in fall prevention. If the client can effectively use the call light, they can request assistance when needed, reducing the risk of falls. It's essential to assess their communication and mobility abilities.

Choice B rationale:

"Create a schedule with an assistive personnel to do hourly rounding for the client." - While hourly rounding is a valuable fall prevention strategy, assessing the client's ability to use the call light should be the initial step to ensure immediate access to help. Rounding can complement this measure.

Choice C rationale:

"Move the bedside table with the client's personal items close to the bed." - While ensuring the client's personal items are within reach is important for their comfort and convenience, it is not the first step in fall prevention. Assessing the client's ability to request assistance takes precedence.

Choice D rationale:

"Apply rubber-soled slippers before ambulation." - Providing appropriate footwear is important for fall prevention, but it is not the first precaution to implement. Assessing the client's ability to use the call light and communicate their needs comes before addressing ambulation.

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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?