A nurse cares for a client who is infected with Burkholderia cepacia.
What action would the nurse take first when admitting this client to a pulmonary care unit?
Instruct the client to wash his or her hands after contact with other people.
Implement Droplet Precautions and don a surgical mask.
Keep the client separated from other clients with cystic fibrosis.
Obtain blood, sputum, and urine culture specimens.
The Correct Answer is C
Choice A rationale
Instructing hand washing is a general infection control measure, but it is not the most critical first action for a client with *Burkholderia cepacia*, especially in a pulmonary unit. *Burkholderia cepacia* poses a significant cross-infection risk, particularly for clients with cystic fibrosis, due to its transmissibility and potential for severe respiratory infections.
Choice B rationale
*Burkholderia cepacia* requires Contact Precautions, not Droplet Precautions. Droplet precautions are for larger respiratory droplets, while *Burkholderia cepacia* transmission is primarily through direct or indirect contact. Incorrect isolation precautions could compromise infection control and put other vulnerable clients at risk.
Choice C rationale
*Burkholderia cepacia* is highly transmissible among individuals with cystic fibrosis and can cause severe, progressive lung disease, known as "cepacia syndrome.”. Isolating the client from others with cystic fibrosis immediately upon admission is paramount to prevent cross-contamination and protect other vulnerable individuals on the unit.
Choice D rationale
While obtaining cultures is important for confirming the diagnosis and guiding treatment, the immediate priority upon admission is to prevent transmission to other susceptible clients, especially those with cystic fibrosis. Implementing isolation measures takes precedence over diagnostic testing in this specific scenario due to the high risk of cross-infection.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Offering plenty of fluids is important for hydration and thinning secretions in asthma, but carbonated beverages can cause gastric distension and worsen respiratory distress by pressing on the diaphragm, making them unsuitable. Furthermore, this intervention does not directly address the acute bronchoconstriction that defines an asthma attack.
Choice B rationale
While humidified oxygen might be indicated for hypoxemia, a cool mist tent is not the primary intervention for acute asthma. The core problem is bronchoconstriction, which requires bronchodilators to open the airways. A cool mist tent offers general comfort but does not provide specific therapeutic relief for the underlying pathophysiology.
Choice C rationale
Administering sedatives to a child experiencing an acute asthma attack is generally contraindicated. Sedation can depress respiratory drive, worsen hypoventilation, and mask signs of worsening respiratory distress, potentially leading to respiratory arrest, especially when the child's respiratory effort is already compromised.
Choice D rationale
Positioning the child with arms resting on the overbed table, often referred to as the "tripod position," allows for the use of accessory respiratory muscles (e.g., sternocleidomastoid, scalenes) to facilitate breathing. This position optimizes lung expansion and reduces the work of breathing by providing a stable base for shoulder girdle muscles to pull up the chest cage.
Correct Answer is D
Explanation
Choice A rationale
Treatment for pulmonary tuberculosis with rifampin is typically prolonged, lasting for several months, often 6 to 9 months, not just 1 month. Shortening the treatment duration significantly increases the risk of drug resistance and recurrence of the infection. Adherence to the full regimen is critical for eradication.
Choice B rationale
Rifampin is not typically associated with causing insomnia. Common side effects include gastrointestinal upset, hepatotoxicity, and discoloration of body fluids. Insomnia is more commonly linked to other medications or underlying conditions, not a characteristic side effect of rifampin directly impacting sleep architecture.
Choice C rationale
Taking rifampin with meals is generally not recommended as food can impair its absorption, reducing its bioavailability and therapeutic effectiveness. It is typically advised to take rifampin on an empty stomach, either 1 hour before or 2 hours after meals, to ensure optimal drug absorption and efficacy.
Choice D rationale
Rifampin causes a harmless but noticeable orange-red discoloration of urine, sweat, tears, and other body secretions. This is due to the drug's inherent color and its excretion pathways. Clients should be informed of this expected side effect to prevent anxiety and ensure adherence to the medication regimen.
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