A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

A. Cachectic, with flaccid muscle tone: Cachexia refers to severe weight loss, muscle wasting, and weakness resulting from chronic malnutrition or underlying disease. Flaccid muscle tone reflects loss of muscle mass and protein stores, which occurs when the body breaks down skeletal muscle for energy during prolonged nutritional deficiency.

B. Skin dry and scaly with bruises on extremities: Poor nutritional status often leads to integumentary changes due to deficiencies in protein, vitamins, and essential fatty acids. Dry, scaly skin can result from inadequate intake of nutrients required for skin maintenance, while easy bruising may occur with deficiencies of vitamin C or vitamin K.

C. Oriented x 3, able to move all extremities: Being oriented to person, place, and time indicates intact cognitive function and adequate cerebral perfusion. The ability to move all extremities reflects preserved neuromuscular function. These findings do not directly indicate malnutrition and instead suggest stable neurological status.

D. Pulse rate 118/min: Tachycardia can occur in various conditions such as dehydration, fever, infection, or hypovolemia. Although severe malnutrition can sometimes contribute to cardiovascular changes, an elevated heart rate in this scenario is more likely related to fever or dehydration from vomiting and diarrhea rather than being a direct indicator of malnutrition.

E. Respiratory rate 18/min: A respiratory rate of 18 breaths per minute falls within the normal adult range of 12–20 breaths per minute. Normal respiratory effort and rate do not indicate nutritional deficiency and therefore do not provide evidence of malnutrition.

F. Abdomen distended: Abdominal distention can occur due to multiple causes including gas accumulation, bowel obstruction, ascites, or gastrointestinal infection. While severe protein deficiency can lead to abdominal swelling in certain conditions, this isolated finding in the context of acute gastrointestinal illness does not specifically indicate malnutrition.

G. Temperature 39.2° C (102.6° F): Fever is a physiological response to infection or inflammation. In this case, the elevated temperature is consistent with the client’s gastrointestinal illness and possible infectious process. Fever itself does not directly indicate malnutrition.

H. BMI 17: A body mass index (BMI) below 18.5 is classified as underweight and suggests inadequate nutritional intake or chronic illness affecting nutritional status. A BMI of 17 indicates significant undernutrition and supports the presence of malnutrition, particularly when accompanied by muscle wasting and cachexia.

A. Place the client in a room with negative-pressure airflow: Tuberculosis is transmitted through airborne droplet nuclei that remain suspended in the air for prolonged periods. Negative-pressure isolation rooms (airborne infection isolation rooms) prevent contaminated air from escaping into surrounding areas by ensuring airflow moves into the room rather than out.

B. Wear gloves when assisting the client with oral care: Standard precautions require the use of gloves when there is potential contact with saliva, mucous membranes, or other body fluids. Oral care involves direct exposure to saliva and respiratory secretions, which may contain Mycobacterium tuberculosis. Wearing gloves reduces the risk of cross-contamination.

C. Limit each visitor to 2-hr increments: Tuberculosis infection control focuses on airborne precautions rather than limiting the duration of visits. Visitors should instead be educated about respiratory protection and may be required to wear appropriate masks. Restricting the length of visits does not reduce transmission if appropriate airborne precautions are already in place.

D. Wear a surgical mask when providing client care: Surgical masks do not provide adequate filtration of airborne droplet nuclei that carry Mycobacterium tuberculosis. Healthcare providers must wear a fit-tested particulate respirator such as an N95 mask to filter small airborne particles. Surgical masks are primarily designed to prevent droplet spread from the wearer.

E. Use antimicrobial sanitizer for hand hygiene: Hand hygiene is a fundamental infection prevention measure even though TB is not primarily transmitted by contact. Alcohol-based hand sanitizers or antimicrobial handwashing reduce the spread of other microorganisms and prevent indirect transmission via contaminated surfaces or hands.