A nurse is assisting with the care of a client who is at 30 weeks of gestation and has tuberculosis. Which of the following actions should the nurse take?
Provide a surgical mask for the client's partner during visits
Initiate airborne precautions for the client.
Tell the client that a cesarean birth is necessary.
Administer penicillin G to the client immediately
The Correct Answer is B
A. Provide a surgical mask for the client's partner during visits: While it is important to protect visitors, providing only a surgical mask is insufficient for tuberculosis precautions. Airborne infections like TB require specialized respirators (such as N95 masks), not just standard surgical masks.
B. Initiate airborne precautions for the client: Tuberculosis is an airborne disease, meaning the client must be placed on airborne precautions. This includes placing the client in a negative pressure room and requiring anyone entering to wear an N95 respirator to prevent transmission.
C. Tell the client that a cesarean birth is necessary: Having tuberculosis does not automatically necessitate a cesarean delivery. If the TB is well controlled and the client is noninfectious by the time of labor, vaginal birth is typically safe.
D. Administer penicillin G to the client immediately: Penicillin G is used to treat infections such as syphilis, not tuberculosis. TB requires a specific antibiotic regimen (such as isoniazid, rifampin, ethambutol, and pyrazinamide), not penicillin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Provide a surgical mask for the client's partner during visits: While it is important to protect visitors, providing only a surgical mask is insufficient for tuberculosis precautions. Airborne infections like TB require specialized respirators (such as N95 masks), not just standard surgical masks.
B. Initiate airborne precautions for the client: Tuberculosis is an airborne disease, meaning the client must be placed on airborne precautions. This includes placing the client in a negative pressure room and requiring anyone entering to wear an N95 respirator to prevent transmission.
C. Tell the client that a cesarean birth is necessary: Having tuberculosis does not automatically necessitate a cesarean delivery. If the TB is well controlled and the client is noninfectious by the time of labor, vaginal birth is typically safe.
D. Administer penicillin G to the client immediately: Penicillin G is used to treat infections such as syphilis, not tuberculosis. TB requires a specific antibiotic regimen (such as isoniazid, rifampin, ethambutol, and pyrazinamide), not penicillin.
Correct Answer is C
Explanation
A. The client tells the nurse he prefers a snack before bedtime: Client food preferences can usually be accommodated by nursing and dietary staff without needing interprofessional team intervention unless related to special dietary restrictions.
B. The client requires reinforcement of teaching about the purpose of his medications: Medication education reinforcement is a routine nursing responsibility and typically does not require escalation to the entire interprofessional team unless there are significant comprehension issues.
C. The client is unable to grasp eating utensils: Difficulty grasping utensils suggests significant motor deficits following the stroke. This functional limitation requires input from occupational therapy, physical therapy, and possibly speech therapy to assess needs for adaptive devices and rehabilitation strategies.
D. The client requests to perform ADLs later in the day: Adjusting the timing of ADLs is a minor scheduling preference and does not necessarily require interprofessional reporting unless it impacts therapy schedules or rehabilitation goals.
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