A nurse is caring for a client who has tuberculosis. The nurse should anticipate which isolation precautions for the client?

Airborne precautions

Protective precautions

Contact precautions

Droplet precautions

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Airborne precautions are necessary for clients with tuberculosis (TB) because TB is an airborne disease. It is transmitted through tiny droplets released into the air when an infected person coughs, sneezes, or talks. These precautions include placing the client in a negative pressure room, using N95 respirators for healthcare workers, and ensuring the client wears a surgical mask when outside their room. These measures help prevent the spread of TB to others.

Choice B Reason:

Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from infections. These precautions are not appropriate for a client with TB, as the primary concern is preventing the spread of TB from the infected client to others, not protecting the client from external infections.

Choice C Reason:

Contact precautions are used for infections that are spread by direct or indirect contact with the patient or their environment, such as MRSA or C. difficile. TB is not spread through contact but through airborne particles, so contact precautions are not sufficient for preventing the transmission of TB.

Choice D Reason:

Droplet precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis. While TB is a respiratory disease, it is spread through much smaller airborne particles that can remain suspended in the air for longer periods, making airborne precautions necessary instead of droplet precautions.

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Correct Answer is C

Explanation

Choice A Reason

Increased heart rate during physical activity can be a common finding in clients who have been on bed rest for an extended period. This is due to deconditioning of the cardiovascular system. While it is important to monitor and address, it is not the most immediate concern compared to other potential complications.

Choice B Reason

Loss of appetite is another common issue in clients who have been on prolonged bed rest. It can lead to nutritional deficiencies and weight loss, which are significant concerns. However, it is not as urgent as other findings that might indicate more acute complications.

Choice C Reason

Left lower extremity tenderness is the most critical finding and should be identified as the priority. This symptom can indicate deep vein thrombosis (DVT), a serious condition that can lead to life-threatening complications such as pulmonary embolism if not promptly addressed. DVT is a common risk for clients who have been immobile for extended periods, making it a top priority for immediate intervention.

Choice D Reason

Musculoskeletal weakness is expected in clients who have been on bed rest for several weeks. It results from muscle atrophy and deconditioning. While it is an important issue to address through rehabilitation and physical therapy, it does not pose an immediate threat to the client’s life compared to the risk of DVT.

A. The client is incapable of providing self-care. B. The client is terminally ill. C. The client is unable to express their wishes. D. The client has refused treatment.

Correct Answer is C

Explanation

Choice A Reason:

The condition that the client is incapable of providing self-care does not necessarily make a durable power of attorney enforceable. While incapacity can be a factor, the key aspect is the client’s ability to make decisions. A durable power of attorney becomes effective when the client is unable to make their own decisions, not merely when they are unable to provide self-care.

Choice B Reason:

Being terminally ill does not automatically make a durable power of attorney enforceable. The enforceability of a durable power of attorney is based on the client’s decision-making capacity. While terminal illness might lead to incapacity, it is the inability to make decisions that triggers the use of the durable power of attorney.

Choice C Reason:

A durable power of attorney is specifically designed to be enforceable when the client is unable to express their wishes. This legal document allows the designated agent to make decisions on behalf of the client when they are incapacitated and unable to communicate their preferences. This ensures that the client’s affairs are managed according to their wishes, even when they cannot express them.

Choice D Reason:

The refusal of treatment by the client does not make a durable power of attorney enforceable. The enforceability is related to the client’s capacity to make decisions. If a client is still capable of making informed decisions, even if they refuse treatment, the durable power of attorney does not come into effect.

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A nurse is caring for a client who has tuberculosis. The nurse should anticipate which isolation precautions for the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?

Correct Answer is C

Explanation

A nurse is providing information to a client about durable power of attorney. The nurse should include that durable power of attorney is enforceable under which of the following conditions?

Correct Answer is C

Explanation

A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

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