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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A sputum culture for acid-fast bacillus (AFB) is considered the gold standard for confirming the diagnosis of active pulmonary tuberculosis. This test directly identifies the presence of Mycobacterium tuberculosis in respiratory secretions, providing definitive evidence of infection and allowing for drug susceptibility testing, which is crucial for guiding treatment.
Choice B rationale
A chest X-ray can show abnormalities suggestive of pulmonary tuberculosis, such as infiltrates, cavitations, or effusions, but it is not definitive. Other respiratory conditions can present similarly, and a chest X-ray alone cannot confirm the presence of active Mycobacterium tuberculosis. It serves as a supportive diagnostic tool.
Choice C rationale
A sputum smear for acid-fast bacilli provides rapid presumptive evidence of active tuberculosis by visualizing AFB under a microscope. While helpful for early detection and isolation precautions, it does not confirm the species of mycobacteria and has lower sensitivity than culture. A positive smear needs confirmation with culture.
Choice D rationale
The Mantoux test, or tuberculin skin test, indicates exposure to Mycobacterium tuberculosis and the development of a cell-mediated immune response. A positive test signifies either latent TB infection or active disease but cannot differentiate between the two. It does not confirm active pulmonary tuberculosis and is not reliable for confirming active disease.
Correct Answer is C
Explanation
Choice A rationale
While a strong support system is beneficial for managing chronic illness, the client's physical presentation (thin and disheveled) suggests potential issues with self-care and functional status. Inquiring about support before assessing their immediate physical needs might overlook critical information directly related to their health and well-being.
Choice B rationale
Assessing the client's understanding of their disease is important for education and adherence, but their current appearance indicates a more immediate need for assessment of their ability to perform basic activities of daily living due to respiratory compromise. Understanding their disease might not directly address their physical decline.
Choice C rationale
The client's appearance (thin and disheveled) strongly suggests a decline in functional status, often linked to increased dyspnea and the energy expenditure required for basic activities. Asking about shortness of breath with activities directly addresses a common and debilitating symptom of COPD that impacts self-care, nutrition, and overall well-being, providing critical assessment data.
Choice D rationale
While medication adherence is vital in COPD management, focusing solely on medications might miss the broader picture of their functional decline and the impact of their symptoms on their ability to perform daily tasks. The physical appearance suggests a more comprehensive assessment of their functional limitations is needed first.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.