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 B
Explanation
Choice A Reason:
Increasing hydration is important in the postoperative period to maintain fluid balance and support recovery. However, it is not the immediate priority following pheochromocytoma removal. The primary concern is to monitor and manage hemodynamic stability, particularly blood pressure.
Choice B Reason:
Monitoring blood pressure is the priority action following pheochromocytoma removal. This surgery can lead to significant fluctuations in blood pressure due to the sudden removal of catecholamine-secreting tumors. Close monitoring is essential to detect and manage potential hypotension or hypertension, which can be life-threatening if not promptly addressed.
Choice C Reason:
Measuring urine output is important for assessing kidney function and fluid balance, but it is not the immediate priority. Blood pressure monitoring takes precedence because of the potential for severe hemodynamic instability following the removal of the tumor.
Choice D Reason:
Providing a calm environment is beneficial for the patient’s overall recovery and can help reduce stress and anxiety. However, it is not the most critical action immediately following surgery. Ensuring hemodynamic stability through blood pressure monitoring is the top priority.
Correct Answer is A
Explanation
Choice A Reason:
A urine specific gravity of 1.02 falls within the normal range (1.005 to 1.03) and indicates that the kidneys are excreting water appropriately. In SIADH, urine is typically concentrated due to excessive antidiuretic hormone (ADH) secretion. A normal urine specific gravity suggests that the ADH levels are normalizing and the condition is resolving.
Choice B Reason:
A sodium level of 119 mEq/L is significantly below the normal range (136 to 145 mEq/L) and indicates persistent hyponatremia. This finding suggests that the SIADH is not resolving, as effective treatment should lead to an increase in serum sodium levels.
Choice C Reason:
A BUN level of 8 mg/dL is slightly below the normal range (10 to 20 mg/dL) but is not a primary indicator of SIADH resolution. BUN levels can be influenced by various factors, including hydration status and renal function.
Choice D Reason:
A calcium level of 8.7 mg/dL is slightly below the normal range (9 to 10.5 mg/dL) but does not directly indicate the resolution of SIADH. Calcium levels are not typically used to monitor the effectiveness of SIADH treatment.
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