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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. An urge to void despite an indwelling catheter may be a normal postoperative sensation due to bladder irritation, but it is not a clear indication of a complication.
B. Output of burgundy colored urine can indicate significant bleeding or a complication such as hemorrhage, which requires immediate attention.
C. A pulse rate of 88/min is within normal limits and does not suggest a postoperative complication.
D. An oral temperature of 38.2° C (100.76° F) is slightly elevated but not uncommon immediately after surgery; it may be monitored but does not immediately indicate a serious complication.

A. 4 mm erythema B. 10 mm wheal C. 5 mm induration D. 15 mm induration

Correct Answer is D

Explanation

A. 4 mm erythema is generally considered negative or not indicative of TB exposure.
B. 10 mm wheal is an inadequate measurement; a wheal indicates a local reaction but not the size of induration.
C. 5 mm induration may be considered positive in high-risk individuals but is generally not sufficient for standard TB testing.
D. 15 mm induration is indicative of a positive TB test, suggesting significant exposure and possible infection. This measurement is used for clients at average risk.

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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?

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Naxlex Comprehensive Predictor Exams

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