A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse plan to implement when working with the client?
Protective
Droplet
Airborne
Contact
The Correct Answer is C
Choice A reason:
Protective precautions are not necessary because they (also known as reverse isolation) are used for immunocompromised clients to protect them from potential pathogens carried by healthcare workers or visitors.
Choice B reason:
Droplet precautions are not necessary because they are used for infections spread through larger respiratory droplets, like influenza or pertussis.
Choice C reason:
Airborne precautions should be implemented by the nurse. Tuberculosis (TB) is primarily transmitted through the airborne route, as the bacteria that cause TB can be suspended in the air as tiny particles (droplet nuclei) when an infected person coughs, sneezes, speaks, or sings. These particles can be inhaled by others, leading to the potential transmission of the disease.
Choice D reason:
Contact precautions are not necessary because they are used for infections that are transmitted through direct contact with the client or contaminated surfaces, such as MRSA (Methicillin-resistant Staphylococcus aureus) or C. difficile.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Evaluating the healing of an incision is not necessary because it involves clinical judgment and assessment skills, which are generally beyond the scope of practice for assistive personnel.
Choice B reason:
Changing IV tubing is a task that can often be safely delegated to an assistive personnel (AP) who has been trained and deemed competent to perform this task. It is within the AP's scope of practice and doesn't require clinical judgment or assessment.
Choice C reason:
Performing a simple dressing change involves direct contact with a wound and requires knowledge of aseptic technique and wound care principles. This task is typically performed by licensed nursing personnel.
Choice D reason:
Inserting an NG tube is a complex procedure that requires specialized training and skill. It should be performed by a licensed nurse or another healthcare professional with the appropriate training and competence.
Correct Answer is D
Explanation
Choice A reason:
Attaching the drainage bag to the side rails of the bed can create tension on the catheter and increase the risk of trauma or dislodgment.
Choice B reason:
Emptying the drainage bag when it is three-quarters full is appropriate to prevent the bag from becoming too heavy and pulling on the catheter. However, this is a practice for maintaining bag weight, not part of the overall care plan.
Choice C reason:
Taping the catheter to the lower abdomen is not recommended. Taping the catheter can cause irritation, tension, and skin breakdown, increasing the risk of infection and trauma to the urethra. The catheter should be secured to the thigh using a catheter securement device if necessary.
Choice D reason:
Keeping the drainage bag below the level of the bladder is the correct recommendation. When caring for a client with an indwelling urinary catheter, it is important to maintain proper catheter and drainage bag positioning to prevent complications. Keeping the drainage bag below the level of the bladder helps promote the free flow of urine, prevent reflux of urine into the bladder, and minimize the risk of urinary tract infections.
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