A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take?
Restrict fresh flowers from the client's room
Have visitors maintain a distance of 1.8 m (6 feet) from the client
Wear a surgical mask when providing client care
Assign the client to a private room with negative air pressure
The Correct Answer is D
Assign the client to a private room with negative air pressure.
Rationale:
- A. Incorrect. Restricting fresh flowers from the client's room is not necessary for infection control purposes. However, some clients with pulmonary tuberculosis may have hypersensitivity reactions to certain plants or flowers, so the nurse should assess the client's allergies before allowing them in the room.
- B. Incorrect. Maintaining a distance of 1.8 m (6 feet) from the client is not sufficient to prevent transmission of tuberculosis. Visitors should also wear a HEPA respirator and limit their contact time with the client.
- C. Incorrect. A surgical mask is not adequate to protect the nurse from inhaling airborne droplet nuclei that contain Mycobacterium tuberculosis. The nurse should wear a high-efficiency particulate air (HEPA) respirator when providing client care.
- D. Correct. Assigning the client to a private room with negative air pressure is the most effective way to prevent the spread of tuberculosis to other clients and staff members. The room should have at least six air exchanges per hour and an exhaust system that vents directly to the outside.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Implement fall precautions for the client.
- A. Implement fall precautions for the client. This is correct because risperidone can cause orthostatic hypotension, which can increase the risk of falls and injuries. The nurse should advise the client to change positions slowly, avoid alcohol and dehydration, and use assistive devices as needed.
- B. Monitor the client's thyroid function. This is incorrect because risperidone does not affect thyroid function. The nurse should monitor the client's thyroid function if they are taking lithium, which can cause hypothyroidism.
- C. Place the client on a fluid restriction. This is incorrect because risperidone does not cause fluid retention or overload. The nurse should encourage adequate fluid intake and monitor the client's fluid balance.
- D. Discontinue the medication if hallucinations occur. This is incorrect because hallucinations are a symptom of schizophrenia, not a side effect of risperidone. The nurse should not discontinue the medication abruptly, as this can cause withdrawal symptoms and relapse of psychosis. The nurse should assess the client's response to the medication, report any adverse effects, and adjust the dosage as prescribed.
Correct Answer is A
Explanation
- A. "We can expect the hospice nurse to provide support for us after our mother's death." This statement indicates that the family understands that hospice care includes bereavement services for up to one year after the death of a loved one.
- B. "A hospice nurse will come to the house each time our mother needs pain medication." This statement indicates that the family does not understand that hospice care involves teaching them how to administer pain medication and other comfort measures to their mother at home.
- C. "Now that my mother is receiving hospice services, we will not be able to get respite care." This statement indicates that the family does not understand that hospice care offers respite care, which allows them to take a break from caregiving for a short period of time.
- D. "Hospice care focuses on arranging treatment that will prolong our mother's life." This statement indicates that the family does not understand that hospice care focuses on providing palliative care, which aims to relieve pain and suffering, rather than curative treatment, which aims to extend life.
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