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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","G"]
Explanation
Choice A rationale:
Blood pressure is a crucial parameter to monitor in a pregnant woman. A significant increase in blood pressure could indicate a condition called preeclampsia, which is characterized by high blood pressure and damage to another organ system, often the liver and kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious — even fatal — complications for both mother and baby.
Choice B rationale:
While the respiratory rate is an important vital sign, it does not directly indicate a prenatal complication in this context. Normal respiratory rates for an adult range from 12 to 20 breaths per minute. Changes could indicate a respiratory problem but not specifically a prenatal complication.
Choice C rationale:
Gravida/parity is a standard way to denote a woman's reproductive history but does not indicate a prenatal complication. Gravida refers to the number of times a woman has been pregnant, regardless of the outcome, while parity refers to the number of pregnancies carried past 20 weeks, regardless of whether they were born alive or stillborn.
Choice D rationale:
Decreased fetal activity can be a sign of distress in the fetus. It could indicate complications such as poor oxygenation or other conditions that could affect the health of the baby. It's important for pregnant women to monitor their baby's movements daily after 28 weeks.
Choice E rationale:
A severe headache unrelieved by acetaminophen in a pregnant woman could be a sign of preeclampsia, especially when accompanied by other symptoms such as high blood pressure and changes in vision. This should be evaluated immediately.
Choice F rationale:
Urine ketones are usually checked in pregnant women who have symptoms of a condition called ketoacidosis, which is often seen in women with gestational diabetes. However, this condition is not indicated in this scenario.
Choice G rationale:
Protein in the urine is another potential sign of preeclampsia. It's caused by kidney problems resulting from the high blood pressure. In normal conditions, protein should not be present in urine or should be very low.
Correct Answer is A
Explanation
Choice A rationale:
Attending a support group to seek help and guidance for handling difficulties indicates the client's acceptance of having a new ileostomy. It demonstrates a proactive approach to coping with the challenges associated with living with an ileostomy.
Choice B rationale:
Having a partner empty the bag for the client to avoid looking at it may indicate avoidance or denial rather than acceptance. While support from a partner is essential, it's also important for the client to actively participate in self-care and adaptation.
Choice C rationale:
Looking forward to having normal bowel movements again may indicate a lack of acceptance or unrealistic expectations since having an ileostomy means a change in bowel function. The client should be educated about the permanence of the ileostomy.
Choice D rationale:
Wishing for a return to the pre-ileostomy sexual relationship may indicate difficulty accepting the changes in body image and function that come with an ileostomy. It may also suggest unrealistic expectations. The client should be encouraged to seek support and counseling for body image issues and sexual concerns.
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