A nurse is caring for a client who was placed on isolation precautions for active pulmonary tuberculosis (TB). Which of the following actions should the nurse plan to take? (Select all that apply.)

Place the client in a room with positive airflow.

Determine whether the client lives alone or with others.

Use an alcohol-based hand cleaner unless hands are visibly soiled.

Remind the client to cover her mouth with a tissue when coughing.

Answer and Explanation

Correct Answer : B,C,D

Choice A reason: Placing a client with active pulmonary TB in a room with positive airflow is not recommended, as positive airflow would push potentially contaminated air into general circulation, risking the spread of TB. Instead, a room with negative airflow is appropriate to contain and remove contaminated air.

Choice B reason: Determining whether the client lives alone or with others is important for public health and contact tracing purposes. If the client lives with others, those individuals may need to be tested and monitored for TB as well.

Choice C reason: Using an alcohol-based hand cleaner is a standard practice unless hands are visibly soiled. If hands are visibly soiled, handwashing with soap and water is necessary.

Choice D reason: Reminding the client to cover their mouth with a tissue when coughing is a key measure to prevent the spread of TB, which is transmitted through airborne particles from coughs or sneezes.

Choice E reason: Antifungal medications are not used to treat TB, which is caused by a bacterium, not a fungus. The client should be instructed about taking anti-tuberculosis medications, not antifungals.

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Correct Answer is A

Explanation

Choice A reason: Thoroughly cleansing the affected area helps remove potential pathogens. The Centers for Disease Control and Prevention (CDC) advises washing needlestick injuries with soap and water.

Choice B reason: Squeezing the puncture site is not recommended because it can cause further injury to the tissue and does not effectively reduce the risk of bloodborne pathogen transmission.

Choice C reason: Flushing the puncture site with water is a good practice, but it should be done immediately, not just for 5 minutes. The initial washing is more critical.

Choice D reason: If indicated, postexposure prophylaxis (PEP) should be initiated as soon as possible, ideally within hours of exposure, to maximize its effectiveness. Delaying PEP until the following day is not advisable.

A. Severity of the condition B. Vital signs C. Nonverbal behavior D. Self-report of pain

Correct Answer is D

Explanation

Choice A reason: The severity of the condition may not always correlate with the level of pain experienced by the client. Pain is a subjective experience, and two individuals with the same condition may report different levels of pain.

Choice B reason: Vital signs can be indicators of pain but are not always reliable. For example, some clients may exhibit increased heart rate or blood pressure when in pain, while others may not show significant changes in vital signs despite severe pain.

Choice C reason: Nonverbal behavior can be an indicator of pain, especially in clients who are unable to communicate verbally. However, it is still considered less reliable than self-report because it is subject to interpretation by the observer.

Choice D reason: Self-report of pain is considered the most reliable indicator of a patient's pain experience. It is a direct expression of the client's experience and should be the primary source of assessment whenever possible.

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A nurse is caring for a client who was placed on isolation precautions for active pulmonary tuberculosis (TB). Which of the following actions should the nurse plan to take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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