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
Request a prescription for an antibiotic. This intervention is not typically included in the standard care plan for all COPD patients. Antibiotics are generally reserved for cases of acute exacerbations of COPD (AECOPD) with signs of bacterial infection, such as increased dyspnea, increased sputum purulence, and increased sputum volume. Routine use of antibiotics without these signs is not recommended.
Choice B Reason
Educate the client on pursed-lip breathing. This is the correct intervention. Pursed-lip breathing is a technique that helps improve ventilation, release trapped air in the lungs, and reduce the work of breathing. It is particularly beneficial for patients with COPD as it helps them manage shortness of breath and improve their breathing efficiency.
Choice C Reason
Place the client on airborne precautions. This intervention is incorrect. COPD is not an infectious disease that requires airborne precautions. Airborne precautions are used for diseases that are transmitted through the air, such as tuberculosis. COPD management focuses on improving lung function and preventing exacerbations.
Choice D Reason
Initiate oxygen therapy for SpO₂ of 92%. This intervention is partially correct but needs clarification. Oxygen therapy is typically initiated for COPD patients with chronic hypoxemia, usually when SpO₂ is less than 88-90%. An SpO₂ of 92% may not necessarily require oxygen therapy unless the patient is experiencing significant symptoms or has other comorbid conditions.
Correct Answer is A
Explanation
Choice A Reason
Expressive aphasia is a common symptom of a left-hemisphere stroke. This condition, also known as Broca’s aphasia, affects the ability to produce language, making it difficult for the patient to speak fluently. The patient may understand speech but struggle to form coherent sentences, often speaking in short, choppy phrases.
Choice B Reason
Poor impulse control is more commonly associated with right-hemisphere strokes. The right hemisphere of the brain is responsible for controlling impulsive behavior and emotional regulation. Therefore, this symptom is less likely to be observed in a patient with a left-hemisphere stroke.
Choice C Reason
Left hemiparesis refers to weakness on the left side of the body. Since the left hemisphere of the brain controls the right side of the body, a left-hemisphere stroke typically results in right-sided weakness or paralysis. Therefore, left hemiparesis is not a typical finding in this scenario.
Choice D Reason
Disorientation to place can occur after a stroke, but it is not specifically associated with left-hemisphere strokes. Disorientation is a general symptom that can result from various types of brain injuries and is not exclusive to strokes affecting the left hemisphere.
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