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A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take?

Restrict fresh flowers from the client's room

Have visitors maintain a distance of 1.8 m (6 feet) from the client

Wear a surgical mask when providing client care

Assign the client to a private room with negative air pressure

Answer and Explanation

The Correct Answer is D

Assign the client to a private room with negative air pressure.

Rationale:

A. Incorrect. Restricting fresh flowers from the client's room is not necessary for infection control purposes. However, some clients with pulmonary tuberculosis may have hypersensitivity reactions to certain plants or flowers, so the nurse should assess the client's allergies before allowing them in the room.
B. Incorrect. Maintaining a distance of 1.8 m (6 feet) from the client is not sufficient to prevent transmission of tuberculosis. Visitors should also wear a HEPA respirator and limit their contact time with the client.
C. Incorrect. A surgical mask is not adequate to protect the nurse from inhaling airborne droplet nuclei that contain Mycobacterium tuberculosis. The nurse should wear a high-efficiency particulate air (HEPA) respirator when providing client care.
D. Correct. Assigning the client to a private room with negative air pressure is the most effective way to prevent the spread of tuberculosis to other clients and staff members. The room should have at least six air exchanges per hour and an exhaust system that vents directly to the outside.

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Correct Answer is C

Explanation

A. Constipation is not a common complication of vacuum-assisted birth. It may be related to other factors such as dehydration, opioid use, or decreased mobility.
B. Urinary urgency is not a common complication of vacuum-assisted birth. It may be related to other factors such as bladder trauma, infection, or diuretic use.
C. Cervical laceration is a common complication of vacuum-assisted birth. It occurs when the vacuum cup causes damage to the cervix during delivery. It can lead to bleeding, infection, or cervical incompetence in future pregnancies.
D. Retained placenta is not a common complication of vacuum-assisted birth. It may be related to other factors such as placenta accreta, uterine atony, or manual removal of the placenta.

A. Uterine rupture. B. Placental abruption. C. Placenta previa. D. Amniotic fluid embolus.

Correct Answer is B

Explanation

Choice A rationale:

Uterine rupture typically presents with intense, constant abdominal pain and signs of shock. However, the absence of visible bleeding in the abdominal cavity makes this choice less likely in this case.

Choice B rationale:

Placental abruption involves the premature separation of the placenta from the uterine wall before delivery. The sudden, severe abdominal pain, moderate vaginal bleeding, persistent uterine contractions, and signs of hypovolemic shock (low blood pressure, rigid abdomen) are indicative of placental abruption. This condition requires immediate medical intervention due to the risk of fetal and maternal compromise.

Choice C rationale:

Placenta previa occurs when the placenta partially or completely covers the cervical opening. It typically presents with painless, bright red vaginal bleeding. The severe abdominal pain described in the scenario is inconsistent with placenta previa.

Choice D rationale:

Amniotic fluid embolus is a rare and life-threatening condition in which amniotic fluid enters the maternal bloodstream, causing an allergic reaction. It can lead to sudden cardiovascular collapse. Although it can cause respiratory distress and hypotension, it does not usually present with severe abdominal pain or uterine contractions.

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A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Explanation

Correct Answer is B

Explanation

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