A nurse is assisting with the care of a client who has pneumonia.

For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.

A) "Ensure that the negative air pressure is active for the client’s room.": Negative air pressure is used for airborne precautions, such as in the case of tuberculosis or other airborne infections. MRSA is primarily spread through direct contact, not airborne transmission, so negative air pressure is not necessary in this situation.

B) "Place the client in a room with a high-efficiency particulate air (HEPA) filter.": A HEPA filter is used for airborne precautions to filter out airborne particles like those found in diseases such as tuberculosis or measles. Since MRSA is transmitted through direct contact and not airborne particles, placing the client in a room with a HEPA filter is not necessary.

C) "Have the client wear a mask when they are out of their room.": MRSA is typically spread by direct contact with infected wounds, bodily fluids, or contaminated surfaces. It is not transmitted via respiratory droplets, so there is no need for the client to wear a mask when they leave their room. The focus should be on contact precautions rather than respiratory precautions.

D) "Don gloves prior to assisting the client with brushing their teeth.": MRSA is a contact-borne infection, so it is essential to use proper personal protective equipment, such as gloves, when coming into direct contact with the client or any of their bodily fluids or contaminated items (such as toothbrushes). Donning gloves prior to assisting with brushing their teeth ensures that the nurse avoids direct contact with potential sources of infection. This is an important measure in preventing the spread of MRSA.

Yellowing of the eyes (Jaundice) → Isoniazid and Rifampin can cause hepatotoxicity, leading to jaundice.

Blurred vision → Ethambutol can cause optic neuritis, leading to blurred vision and color blindness.

Dry eyes (Incorrect) → Not a common side effect of TB medications.

Gastrointestinal:

Abdominal pain → Isoniazid, Rifampin, and Pyrazinamide are hepatotoxic and can cause liver inflammation and gastric irritation.

Weight gain (Incorrect) → TB medications are more likely to cause weight loss rather than gain.

Hematologic:

Increased bruising & bleeding tendencies → Rifampin can cause thrombocytopenia, increasing the risk of bruising and bleeding.

Insomnia (Incorrect) → Not a serious adverse effect of TB medications.

Genitourinary:

Darkening of the urine → Rifampin causes orange-red discoloration of urine, sweat, and tears, which is a benign but expected effect.

Urinary frequency (Incorrect) → Not a known adverse effect of TB medications.