A nurse is preparing for the admission of a client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?
Have staff and visitors wear gowns, masks, and gloves while in the client's room.
Modify the protocol for donning and removing personal protective equipment before entering or leaving the client's room.
Assign the client to a room with other clients who require droplet precautions.
Place the client in a private room with a special ventilation system.
The Correct Answer is D
A. Gowns and gloves are not required for TB precautions; a mask is necessary to protect against airborne transmission.
B. Standard protocols for personal protective equipment (PPE) should be followed, but they do not specifically address the need for specialized precautions in TB care.
C. Clients with TB should not be placed in a room with others, even those requiring droplet precautions, due to the risk of airborne transmission.
D. A private room with a special ventilation system, such as negative pressure, is essential for isolating clients with active TB to prevent airborne transmission.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","F","G"]
Explanation
A. Temperature: The client has a fever (39.3°C/102.8°F) indicating a potential infection or inflammatory process. This requires immediate follow-up to address the underlying cause of the fever.
B. Blood pressure: The client’s blood pressure is low (84/58 mm Hg on admission and 88/58 mm Hg current), suggesting possible shock or severe dehydration. This finding requires immediate assessment and intervention.
C. Pain level: The client reports increasing back and suprapubic pain, which could be related to a urinary tract infection or other serious condition. Addressing pain and its cause is critical.
D. Adalimumab frequency: The current medication schedule for Adalimumab is less urgent compared to the acute findings. The frequency of this medication does not require immediate follow-up in this context.
E. Heart sounds: No dysrhythmias were noted on the cardiac monitor, so this finding does not require immediate follow-up at this time.
F. WBC count: The WBC count is elevated with leucocyte esterase positive, indicating an infection. This warrants immediate attention to diagnose and treat the infection.
G. Urinalysis: The urinalysis shows cloudy appearance, foul odor, and alkaline pH with positive leucocyte esterase, suggesting a urinary tract infection. This requires immediate follow-up to start appropriate treatment.
H. Hgb & Hct: While important, these values are not provided in the current context. The immediate concerns are more focused on the acute symptoms and signs provided.
Correct Answer is C
Explanation
A. Deflating the balloons regularly is not a standard practice and could potentially lead to rebleeding; balloon inflation should be managed carefully as per protocol.
B. Suctioning the tube should be done based on the need for patency, but every 2 hours might not be necessary unless indicated.
C. Maintaining constant observation while the balloons are inflated is crucial to monitor for complications such as esophageal tissue necrosis and to ensure effective hemostasis.
D. The head of the bed should typically be elevated to reduce the risk of aspiration and facilitate breathing, rather than kept flat.
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