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 C

Explanation

Choice A reason: Regular morning exercise can actually promote better sleep. It helps to regulate the body's clock and can lead to deeper, more restful sleep. However, exercising too close to bedtime may have the opposite effect.

Choice B reason: Going to bed at the same time every evening can help establish a consistent sleep-wake cycle, which is beneficial for people who have insomnia. This regularity can make it easier to fall asleep and wake up naturally.

Choice C reason: Alcohol consumption before bedtime can disrupt sleep patterns. While it may initially help someone fall asleep, it often leads to poorer quality of sleep and can cause awakenings throughout the night.

Choice D reason: If unable to sleep, getting out of bed can be a good strategy. It's part of stimulus control therapy for insomnia, which advises leaving the bed if you can't sleep, so you don't associate the bed with wakefulness

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.)

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Correct Answer is C

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Explanation

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