A nurse is assisting with the care of a client.

Vital Signs.

1330: Temperature 36.8 °C (98.2 °F) Heart rate 88/min.

Respiratory rate 16/min.

Blood pressure 110/64 mm Hg. 1345: Oxygen saturation 96% on 3 L/min via simple face mask.

Temperature 37 °C (98.6 °F) Heart rate 112/min.

Respiratory rate 20/min.

Blood pressure 108/60 mm Hg. 1400: Oxygen saturation 94% on 3 L/min via simple face mask.

Temperature 38.3 °C (101 °F) Heart rate 152/min.

For each data collection finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.

Each finding may support more than 1 disease process.

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.

Choice A rationale:

Supplement spoken language with pictures. Rationale: When caring for a client who speaks a different language, supplementing spoken language with pictures or visual aids is a helpful communication strategy. Visual aids can assist in conveying important information, instructions, and concepts effectively, especially when there is a language barrier.

Choice B rationale:

Ask a family member of the client to interpret. Rationale: Relying on a family member to interpret can be problematic, as it may compromise the privacy and confidentiality of the client's healthcare information. Additionally, family members may not always be available or proficient in the required language, making it an unreliable method of communication.

Choice C rationale:

Recognize that the client nodding indicates an understanding of the information. Rationale: Assuming that nodding indicates understanding is not a reliable approach, as nodding can have different cultural interpretations and may not necessarily indicate comprehension. It is important to use clear and simple language, along with visual aids when necessary, to ensure effective communication.

Choice D rationale:

Speak to the client at an increased volume. Rationale: Speaking at an increased volume is not an appropriate approach to communication with a client who speaks a different language. It can be perceived as rude or aggressive and is unlikely to improve understanding. Clear and concise communication, along with visual aids or interpretation services when needed, is a more effective strategy.