A nurse is contributing to the plan of care for a client who was newly admitted and has tuberculosis. Which of the following actions should the nurse recommend Including in the plan of care?

Initiate contact precautions.

Increase the client's daily intake of vitamin D.

Perform tuberculin skin testing.

Place the client in a positive-pressure isolation room.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Contact precautions are not sufficient for tuberculosis (TB), which is an airborne infection. Instead, airborne precautions should be initiated.

Choice B Reason:

Increasing the client's daily intake of vitamin D may be considered as a complementary measure to support the immune system.

Choice C Reason:

Performing tuberculin skin testing (TST) is a diagnostic test for TB but is typically not included in the plan of care for a newly admitted client with confirmed TB.

Choice D Reason:

Placing the client in a positive-pressure isolation room is not the recommended isolation method for clients with TB. Negative-pressure isolation rooms help prevent the spread of infectious airborne diseases like TB.

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Correct Answer is C

Explanation

Choice A Reason:

Pain sensation is incorrect. While assessing pain is important, it's generally secondary to addressing the life-threatening cardiac issues in hypothermia. Pain assessment can be done once the client's core temperature is stabilized.

Choice B Reason:

Urinary output is incorrect. Monitoring urinary output is essential for assessing kidney function and fluid balance, but it is not as immediately critical as assessing and addressing cardiac concerns.

In a client with hypothermia, the priority for the nurse to monitor is:

Choice C Reason:

Heart rhythm is correct. Hypothermia can affect the electrical conductivity of the heart, potentially leading to life-threatening arrhythmias. Monitoring the client's heart rhythm is essential to detect any abnormalities and intervene promptly if necessary. While all the listed parameters are important, the cardiac status takes precedence due to the immediate threat it poses to the client's life.

Choice D Reason:

- Muscle strength is incorrect. Monitoring muscle strength is important to assess the client's overall neurological status, but it's not the top priority when there is a risk of life-threatening arrhythmias due to hypothermia.

A. Changing the appliance on a new colostomy B. Performing indwelling urinary catheter care C. Demonstrating how to use an incentive spirometer D. Measuring the depth of a stage 3 pressure injury

Correct Answer is B

Explanation

Choice A Reason:

A. Changing the appliance on a new colostomy requires specialized knowledge of ostomy care and assessment, including assessing stoma health and proper technique.

Choice B Reason:

This is an appropriate task to delegate to an AP. APs are trained to perform basic tasks like catheter care under the supervision of a nurse.

Choice C Reason

Demonstrating how to use an incentive spirometer involves patient education and assessment of the patient's ability to perform the procedure correctly, which requires clinical judgment and teaching skills and should not be delegated to an AP.

Choice D Reason:

This task involves assessing the wound, which requires clinical judgment and should be done by a nurse, not an AP.

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A nurse is contributing to the plan of care for a client who was newly admitted and has tuberculosis. Which of the following actions should the nurse recommend Including in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5" C (90.5). Which of the following data is the priority for the nurse to monitor?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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