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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
A. Irregular menses is incorrect. Oral contraceptives are often prescribed to regulate menstrual cycles and can be a suitable option for clients with irregular menses.
Choice B Reason:
Vaginal yeast infection is incorrect. Vaginal yeast infections do not generally contraindicate the use of oral contraceptives.
Choice C Reason:
Hypertension (high blood pressure) is a contraindication for the use of oral contraceptives. Women with hypertension are at an increased risk of cardiovascular complications when taking hormonal contraceptives. It is important to assess and manage blood pressure before considering the use of oral contraceptives. If a client has hypertension, alternative methods of contraception should be discussed with the healthcare provider.
Choice D Reason:
History of ectopic pregnancy is incorrect. A history of ectopic pregnancy may not be a contraindication for oral contraceptives, but it is essential for the healthcare provider to assess the client's individual medical history and discuss the risks and benefits.
Correct Answer is D
Explanation
Choice A Reason:
Documenting the infiltration is important for the client's medical record, but it should not be the first action when infiltration is suspected.
Choice B Reason:
Elevating the arm can help reduce swelling, but it should come after stopping the infusion.
Choice C Reason:
Applying a warm compress can help with comfort and may be done after stopping the infusion, but it is not the first action.
Choice D Reason:
Stop the infusion is correct. When a nurse observes signs of infiltration around an IV insertion site, such as edema and coolness of the skin, the first and most important action is to stop the infusion immediately. Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of going into the vein. Stopping the infusion prevents further damage to the surrounding tissue and minimizes the risk of complications.
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