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: The first step after a needlestick injury is to wash the wound with soap and water to reduce the risk of infection. This helps to remove any pathogens that may have been introduced into the puncture site.

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: Postexposure prophylaxis (PEP) should be started as soon as possible, ideally within hours and no later than 72 hours after potential exposure to HIV. Waiting until the following day could decrease the effectiveness of PEP.

A. Expect the client to express his pain both verbally and nonverbally. B. Administer opioids with caution because they will eventually lead to addiction. C. To achieve fast-acting pain relief, administer analgesics orally. D. Use a scale from 0 to 10 to monitor the severity of the client's pain. E. Observe the clients pain expression

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Expecting the client to express pain both verbally and nonverbally is important in postoperative care. Pain expression is subjective and can vary greatly among individuals. Some clients may verbalize their discomfort, while others may exhibit nonverbal cues such as grimacing, restlessness, or guarding the affected area. It is crucial for nurses to be attentive to all forms of pain expression to assess and manage the client's pain effectively.

Choice B reason: Administering opioids with caution is a standard practice due to the risk of addiction; however, the statement that they will eventually lead to addiction is misleading. Opioids, when used appropriately and under medical supervision, are an effective component of postoperative pain management. The risk of addiction is present but can be mitigated through careful monitoring, patient education, and using the lowest effective dose for the shortest duration necessary.

Choice C reason: Administering analgesics orally for fast-acting pain relief is a common practice, especially when immediate onset is not required. Oral administration is non-invasive and convenient, but it is not the fastest method for pain relief compared to intravenous administration. The choice of analgesic and the route of administration should be based on the client's pain level, type of surgery, and individual needs.

Choice D reason: Using a pain scale from 0 to 10 is an effective way to monitor the severity of the client's pain. This method provides a quantifiable measure of pain intensity, allowing for consistent assessment and facilitating communication between the client and healthcare providers. It helps in evaluating the effectiveness of pain management interventions and in making necessary adjustments to the pain management plan.

Choice E reason: Considering the client's individual expression of pain is essential in postoperative care. Pain is a personal experience, and what may be tolerable for one person could be unbearable for another. Factors such as cultural background, previous pain experiences, psychological state, and the presence of comorbidities can influence pain perception. Tailoring pain management strategies to the individual's needs and preferences is key to effective pain control.

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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

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is ["A","C","D","E"]

Explanation

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