A nurse is caring for a client who is suspected to have active laryngeal tuberculosis (TB). Which of the following actions should the nurse plan to take to safely care for this client?

Have staff and visitors wear gowns while in the client’s room.

Place the client in a private room with a special ventilation system.

Move the client to a semi-private room with a client who requires droplet precautions.

Remove personal protective equipment in the hallway outside of the client’s room.

Answer and Explanation

The Correct Answer is B

Choice A reason: While gowns may be part of the precautions, they are not sufficient alone for preventing the spread of TB, which is transmitted via airborne particles.

Choice B reason: Placing the client in a private room with a special ventilation system is crucial for preventing the spread of TB. The special ventilation system, typically a negative pressure room, ensures that airborne particles do not escape into other areas, thereby protecting staff and other patients.

Choice C reason: A semi-private room with another patient requiring droplet precautions is inappropriate for a TB patient, as TB requires strict airborne precautions to prevent transmission.

Choice D reason: Removing personal protective equipment in the hallway increases the risk of contaminating the hallway and spreading TB. PPE should be removed inside the room or anteroom to contain potential contaminants.

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Correct Answer is D

Explanation

Choice A reason: A dry raised rash is not a typical finding in scleroderma. Scleroderma primarily affects the skin and connective tissues, leading to hardening and tightening of the skin.

Choice B reason: Excessive salivation is not associated with scleroderma. Clients with scleroderma may experience dry mouth (xerostomia) instead.

Choice C reason: Periorbital edema is not a characteristic feature of scleroderma. Scleroderma involves systemic sclerosis that affects the skin, blood vessels, and internal organs.

Choice D reason: The correct answer is d because hardened skin is a hallmark of scleroderma. This autoimmune disease causes the skin to become thickened, tight, and stiff due to excessive collagen deposition.

A. A client who has a splinted open fracture of the left medial malleolus. B. A client who has a penetrating head injury and is experiencing seizures. C. A client who has severe respiratory stridor and a deviated trachea. D. A client who has a small circular partial-thickness burn of the left calf.

Correct Answer is C

Explanation

Choice A reason: An open fracture, while needing medical attention, is not immediately life-threatening. The client's condition is stable enough to wait while more critical cases are attended to.

Choice B reason: A penetrating head injury with seizures is a critical condition. However, ensuring a patent airway takes precedence in emergency situations. This client's seizures indicate serious brain injury, but the immediate threat to life, such as airway obstruction, must be prioritized.

Choice C reason: Severe respiratory stridor and a deviated trachea indicate a life-threatening airway obstruction. This client needs immediate attention to secure the airway and prevent respiratory failure. This is the highest priority because without a clear airway, the client will not survive long enough to benefit from other interventions.

Choice D reason: A partial-thickness burn, although painful and requiring treatment, is not immediately life-threatening. This client can safely wait while those with more critical needs are attended to.

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A nurse is caring for a client who is suspected to have active laryngeal tuberculosis (TB). Which of the following actions should the nurse plan to take to safely care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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