A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching?

- A. This choice is incorrect because an older adult client who reports constipation of 4 days is not an urgent situation that requires immediate attention. The nurse should assess the client's hydration status, bowel habits, and medication use, and provide education on dietary and lifestyle modifications to prevent constipation.

- B. This choice is incorrect because a preschooler who has a skin rash is not an urgent situation that requires immediate attention. The nurse should assess the type, location, and distribution of the rash, as well as any history of allergies, exposure, or infection, and provide appropriate treatment and education.

- C. This choice is incorrect because an adolescent who has a closed fracture is not an urgent situation that requires immediate attention. The nurse should assess the site of injury, neurovascular status, pain level, and immobilization device, and provide analgesia and education on fracture care.

- D. This choice is correct because a middle adult client who has unstable vital signs is an urgent situation that requires immediate attention. The nurse should assess the client's level of consciousness, airway, breathing, circulation, and possible causes of instability, and initiate lifesaving interventions.

Assign the client to a private room with negative air pressure.

Rationale:

• A. Incorrect. Restricting fresh flowers from the client's room is not necessary for infection control purposes. However, some clients with pulmonary tuberculosis may have hypersensitivity reactions to certain plants or flowers, so the nurse should assess the client's allergies before allowing them in the room.
• B. Incorrect. Maintaining a distance of 1.8 m (6 feet) from the client is not sufficient to prevent transmission of tuberculosis. Visitors should also wear a HEPA respirator and limit their contact time with the client.
• C. Incorrect. A surgical mask is not adequate to protect the nurse from inhaling airborne droplet nuclei that contain Mycobacterium tuberculosis. The nurse should wear a high-efficiency particulate air (HEPA) respirator when providing client care.
• D. Correct. Assigning the client to a private room with negative air pressure is the most effective way to prevent the spread of tuberculosis to other clients and staff members. The room should have at least six air exchanges per hour and an exhaust system that vents directly to the outside.