A nurse is caring for a client who has a wound infection that contains vancomycin-resistant Enterococcus (VRE). Which of the following types of precautions should the nurse plan to take while caring for this client?

Choice A reason: Droplet precautions are used for diseases that are spread by large respiratory droplets produced by coughing, sneezing, or talking. Examples include influenza, pertussis, and mumps. However, tuberculosis is not spread through large droplets but through airborne particles that can remain suspended in the air for long periods.

Choice B reason: Airborne precautions are necessary for diseases that are transmitted by smaller droplets, which can be suspended in the air for extended periods and can be inhaled. Tuberculosis, particularly pulmonary or laryngeal tuberculosis with a productive cough, requires airborne precautions because the bacteria can be expelled into the air and inhaled by others. The nurse should initiate airborne precautions, which include placing the patient in a negative pressure room and using personal protective equipment such as N95 respirators.

Choice C reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. Examples include infections caused by multidrug-resistant organisms, scabies, and norovirus. Tuberculosis is not spread by direct contact, so contact precautions are not the primary method of prevention.

Choice D reason: Protective isolation, also known as neutropenic or reverse isolation, is used to protect immunocompromised patients from infections. It is not used for patients with tuberculosis, as the goal is to protect others from the tuberculosis bacteria, not to protect the patient from external infections.

The correct answer is: c. Positioning the client’s arm above heart level.

Choice A: Wrapping the cuff too loosely around the client’s arm

Wrapping the cuff too loosely can lead to an inaccurately high blood pressure reading, not a low one. A loose cuff does not compress the artery properly, causing the device to overestimate the pressure needed to occlude the artery.

Choice B: Measuring blood pressure right after the client’s mealtime

Measuring blood pressure right after a meal can cause a slight increase in blood pressure due to the body’s metabolic response to digestion. This is not a common cause of a low blood pressure reading.

Choice C: Positioning the client’s arm above heart level

Positioning the client’s arm above heart level can lead to an inaccurately low blood pressure reading. When the arm is elevated, the hydrostatic pressure decreases, resulting in a lower reading. This is a well-known source of error in blood pressure measurement.

Choice D: Deflating the cuff too slowly

Deflating the cuff too slowly can cause venous congestion, which may lead to an inaccurately high reading rather than a low one. The standard deflation rate is 2-3 mm Hg per second to ensure accurate measurement.