A nurse is caring for a client who has active tuberculosis. Which of the following actions should the nurse take?
Remain 1 m (3 feet) away from the client when providing care.
Apply a surgical mask before entering the client’s room.
Ensure the door to the client’s room is closed at all times.
Place a “no visitors” sign on the client’s door.
The Correct Answer is C
Choice A Reason:
Remaining 1 meter (3 feet) away from the client when providing care is not sufficient to prevent the spread of tuberculosis (TB). TB is an airborne disease, and the bacteria can remain suspended in the air for several hours. Therefore, maintaining a distance alone does not provide adequate protection against inhaling the bacteria.
Choice B Reason:
Applying a surgical mask before entering the client’s room is not the most effective measure. Surgical masks are designed to protect against large droplets and splashes, but they do not provide adequate protection against airborne particles like TB bacteria. Instead, healthcare workers should use N95 respirators, which are specifically designed to filter out airborne particles.
Choice C Reason:
Ensuring the door to the client’s room is closed at all times is a critical measure in preventing the spread of TB. This action helps to contain the airborne bacteria within the room, reducing the risk of transmission to others in the healthcare facility. This is part of airborne precautions, which are essential for managing patients with active TB.
Choice D Reason:
Placing a “no visitors” sign on the client’s door can help limit the number of people exposed to the TB bacteria, but it is not the most critical action. While it is important to restrict visitors, ensuring the door is closed and using appropriate personal protective equipment (PPE) are more effective measures in controlling the spread of TB.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason
Lidocaine is primarily used to treat ventricular arrhythmias, such as ventricular tachycardia or ventricular fibrillation. It is not typically used for bradycardia (a heart rate of 40/min) and would not be appropriate for this scenario.
Choice B Reason
Adenosine is used to treat certain types of supraventricular tachycardia (SVT) by slowing down the heart rate. It is not indicated for bradycardia and would not be suitable for a heart rate of 40/min.
Choice C Reason
Atropine is the first-line medication for treating symptomatic bradycardia. It works by blocking the effects of the vagus nerve on the heart, thereby increasing the heart rate. Given the client’s symptoms of a low heart rate, diaphoresis, and chest pain, atropine is the appropriate choice.
Choice D Reason
Verapamil is a calcium channel blocker used to treat high blood pressure, angina, and certain types of arrhythmias. However, it is not used for bradycardia and could potentially worsen the condition by further lowering the heart rate.
Correct Answer is B
Explanation
Choice A Reason:
The dressing for a PICC line should be changed every 7 days or sooner if it becomes wet, soiled, or loose. Therefore, a dressing change 7 days ago is within the recommended guidelines and does not necessarily require immediate notification of the provider.
Choice B Reason:
An increase in the circumference of the client’s upper arm by 10% can indicate swelling, which may be a sign of complications such as infection, thrombosis, or infiltration. This finding should be promptly reported to the provider for further evaluation and intervention.
Choice C Reason:
The catheter not being used for 8 hours is not typically a cause for concern as long as it is properly flushed and maintained. PICC lines can remain in place for extended periods without use, provided they are flushed regularly to prevent occlusion.
Choice D Reason:
Flushing the catheter with 10 mL of sterile saline after medication use is a standard practice to maintain patency and prevent blockage This action does not require notification of the provider unless there are other associated complications.
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