The nurse is reviewing the client's medical record.

Exhibits

The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

A. Raises all four side-rails on the client's bed. Raising all four side-rails can create a risk for falls, as it may lead to a false sense of security and prevent the client from being able to exit the bed safely if needed. Additionally, it can increase the risk of entrapment or injury. The recommended practice is to keep two side-rails up while allowing for easy access and mobility for the client.
B. Locks the wheels on the client's bed. Locking the wheels on the client's bed is an appropriate action. This prevents the bed from rolling and helps ensure the client's safety, particularly when they are getting in and out of bed or during care activities.
C. Assists the client to the bathroom every 2 hr. Assisting the client to the bathroom every 2 hours is a reasonable intervention for a client at risk for falls, as it promotes regular toileting and prevents the need for urgent trips to the bathroom that could increase the risk of falling.
D. Clears furniture from the path leading to the bathroom. Clearing furniture from the path leading to the bathroom is a proactive safety measure. This reduces obstacles and hazards, promoting a safer environment for the client and minimizing the risk of falls during ambulation.

Rationale for Correct Choices:

• N95 respirator. The client’s presentation of a cough, fatigue, night sweats, weight loss, and positive sputum culture for M. tuberculosis strongly suggests active tuberculosis (TB). Tuberculosis is transmitted through airborne particles, and an N95 respirator is required to protect healthcare workers from inhaling these particles. The N95 mask is specifically designed to filter out small particles, including the Mycobacterium tuberculosis bacteria.
• Gloves. Gloves should be worn when caring for patients with suspected or confirmed TB to prevent contact transmission. While TB is primarily transmitted via airborne particles, gloves are still necessary to protect healthcare workers from coming into contact with bodily fluids such as sputum or any other potentially contaminated materials.

Rationale for Incorrect Options:

• Face shield. A face shield is not required as primary protection for TB. While face shields can protect against splashes and droplets, TB is primarily transmitted via airborne particles, for which an N95 respirator is more appropriate.
• Surgical mask. A surgical mask is not sufficient for protecting healthcare workers against tuberculosis because it does not filter out small airborne particles like the N95 respirator does. Surgical masks are primarily intended for droplet precautions, but tuberculosis is spread through airborne transmission, necessitating an N95 mask for adequate protection.

• Gown. A gown is not required in this situation unless the patient has other symptoms or conditions that increase the risk of contamination, such as excessive wound drainage or the potential for body fluid splashes. For TB transmission, the primary concern is airborne transmission, and appropriate PPE focuses on respiratory protection (N95) and gloves for contact precautions.