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

Remain 1 m (3 feet) away from the client when providing care.

Apply a surgical mask before entering the client’s room.

Ensure the door to the client’s room is closed at all times.

Place a “no visitors” sign on the client’s door.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Remaining 1 meter (3 feet) away from the client when providing care is not sufficient to prevent the spread of tuberculosis (TB). TB is an airborne disease, and the bacteria can remain suspended in the air for several hours. Therefore, maintaining a distance alone does not provide adequate protection against inhaling the bacteria.

Choice B Reason:

Applying a surgical mask before entering the client’s room is not the most effective measure. Surgical masks are designed to protect against large droplets and splashes, but they do not provide adequate protection against airborne particles like TB bacteria. Instead, healthcare workers should use N95 respirators, which are specifically designed to filter out airborne particles.

Choice C Reason:

Ensuring the door to the client’s room is closed at all times is a critical measure in preventing the spread of TB. This action helps to contain the airborne bacteria within the room, reducing the risk of transmission to others in the healthcare facility. This is part of airborne precautions, which are essential for managing patients with active TB.

Choice D Reason:

Placing a “no visitors” sign on the client’s door can help limit the number of people exposed to the TB bacteria, but it is not the most critical action. While it is important to restrict visitors, ensuring the door is closed and using appropriate personal protective equipment (PPE) are more effective measures in controlling the spread of TB.

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Correct Answer is B

Explanation

Choice A Reason

Apply an ice pack directly to the affected area. This statement is incorrect. Applying ice to a snake bite can cause more harm than good. Ice can restrict blood flow and potentially increase tissue damage. The recommended approach is to keep the bite area still and at or below heart level to slow the spread of venom.

Choice B Reason

Immobilize the affected extremity with a splint. This is the correct intervention. Immobilizing the affected limb helps to slow the spread of venom by reducing movement. Keeping the limb still and using a splint can prevent the venom from circulating more rapidly through the body.

Choice C Reason

Place a tourniquet above and below the affected area. This statement is incorrect. Using a tourniquet is not recommended for snake bites as it can cause severe damage to the affected limb by cutting off blood flow completely. This can lead to tissue death and other complications.

Choice D Reason

Elevate the affected extremity. This statement is incorrect. Elevating the limb can increase the spread of venom. The affected limb should be kept at or below heart level to slow the venom’s spread.

A. Lidocaine B. Adenosine C. Atropine D. Verapamil

Correct Answer is C

Explanation

Choice A Reason

Lidocaine is primarily used to treat ventricular arrhythmias, such as ventricular tachycardia or ventricular fibrillation. It is not typically used for bradycardia (a heart rate of 40/min) and would not be appropriate for this scenario.

Choice B Reason

Adenosine is used to treat certain types of supraventricular tachycardia (SVT) by slowing down the heart rate. It is not indicated for bradycardia and would not be suitable for a heart rate of 40/min.

Choice C Reason

Atropine is the first-line medication for treating symptomatic bradycardia. It works by blocking the effects of the vagus nerve on the heart, thereby increasing the heart rate. Given the client’s symptoms of a low heart rate, diaphoresis, and chest pain, atropine is the appropriate choice.

Choice D Reason

Verapamil is a calcium channel blocker used to treat high blood pressure, angina, and certain types of arrhythmias. However, it is not used for bradycardia and could potentially worsen the condition by further lowering the heart rate.

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

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