A nurse is assisting with the care of a client who is at 30 weeks of gestation and has tuberculosis. Which of the following actions should the nurse take?
Provide a surgical mask for the client's partner during visits
Initiate airborne precautions for the client.
Tell the client that a cesarean birth is necessary.
Administer penicillin G to the client immediately
The Correct Answer is B
A. Provide a surgical mask for the client's partner during visits: While it is important to protect visitors, providing only a surgical mask is insufficient for tuberculosis precautions. Airborne infections like TB require specialized respirators (such as N95 masks), not just standard surgical masks.
B. Initiate airborne precautions for the client: Tuberculosis is an airborne disease, meaning the client must be placed on airborne precautions. This includes placing the client in a negative pressure room and requiring anyone entering to wear an N95 respirator to prevent transmission.
C. Tell the client that a cesarean birth is necessary: Having tuberculosis does not automatically necessitate a cesarean delivery. If the TB is well controlled and the client is noninfectious by the time of labor, vaginal birth is typically safe.
D. Administer penicillin G to the client immediately: Penicillin G is used to treat infections such as syphilis, not tuberculosis. TB requires a specific antibiotic regimen (such as isoniazid, rifampin, ethambutol, and pyrazinamide), not penicillin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypertension: Clients experiencing diabetic ketoacidosis (DKA) are more likely to present with hypotension rather than hypertension due to dehydration caused by osmotic diuresis. Volume depletion significantly lowers blood pressure rather than raising it in the setting of DKA.
B. Fruity breath odor: A fruity or acetone-like breath odor is a hallmark sign of DKA. It results from the accumulation of ketones, particularly acetone, in the blood, which the body attempts to eliminate through the lungs, giving the breath its characteristic sweet or fruity smell.
C. Protruding eyeballs: Protruding eyeballs, or exophthalmos, are associated with hyperthyroidism, particularly Graves' disease, not with diabetic ketoacidosis. DKA affects metabolic and acid-base balance but does not cause changes to eye appearance or positioning.
D. Decreased urinary output: In the early stages of DKA, clients usually experience increased urinary output (polyuria) due to osmotic diuresis from hyperglycemia. Decreased output may occur only in the later stages when severe dehydration and kidney compromise develop, but it is not an early expected finding.
Correct Answer is B
Explanation
A. Hypertension: Hyponatremia typically leads to hypotension due to fluid shifts out of the vascular space rather than hypertension, especially if it is associated with hypovolemia. Low sodium levels can reduce blood volume and pressure, making hypertension an unlikely finding in this condition.
B. Muscle cramps: Muscle cramps are a common symptom of hyponatremia due to disrupted electrolyte balance affecting neuromuscular function. Low sodium levels impair muscle contraction and nerve signal transmission, leading to cramps, weakness, and fatigue.
C. Blurred vision: Blurred vision is not a typical manifestation of hyponatremia. While severe hyponatremia can cause neurological symptoms like confusion or seizures, visual disturbances like blurred vision are not primary signs linked to sodium imbalance.
D. Constipation: Constipation is more often associated with dehydration, immobility, or other electrolyte imbalances such as hypercalcemia. Hyponatremia primarily affects neuromuscular and central nervous system function rather than gastrointestinal motility.
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