A nurse is caring for a client who is suspected to have active laryngeal tuberculosis (TB). Which of the following actions should the nurse plan to take to safely care for this client?

Have staff and visitors wear gowns while in the client’s room.

Place the client in a private room with a special ventilation system.

Move the client to a semi-private room with a client who requires droplet precautions.

Remove personal protective equipment in the hallway outside of the client’s room.

Answer and Explanation

The Correct Answer is B

Choice A reason: While gowns may be part of the precautions, they are not sufficient alone for preventing the spread of TB, which is transmitted via airborne particles.

Choice B reason: Placing the client in a private room with a special ventilation system is crucial for preventing the spread of TB. The special ventilation system, typically a negative pressure room, ensures that airborne particles do not escape into other areas, thereby protecting staff and other patients.

Choice C reason: A semi-private room with another patient requiring droplet precautions is inappropriate for a TB patient, as TB requires strict airborne precautions to prevent transmission.

Choice D reason: Removing personal protective equipment in the hallway increases the risk of contaminating the hallway and spreading TB. PPE should be removed inside the room or anteroom to contain potential contaminants.

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Correct Answer is C

Explanation

Choice A reason: Applying lotion to the skin around the edges of the splint may increase moisture and friction, which can contribute to skin breakdown. It is better to use protective dressings to reduce friction.

Choice B reason: Turning the client every 4 hours is not frequent enough. Clients in skeletal traction should be repositioned frequently, typically every 2 hours, to prevent pressure ulcers and maintain skin integrity.

Choice C reason: The correct answer is c because padding the top of the splint with protective dressings helps reduce friction and pressure on the skin, preventing skin breakdown and ensuring the client's comfort.

Choice D reason: Applying a footplate to the bed is not directly related to preventing skin breakdown. The primary focus should be on reducing friction and pressure around the splint.

A. Limit fluid intake. B. Monitor client’s cardinal fields of vision. C. Encourage ambulation. D. Ensure the room is brightly lit.

Correct Answer is B

Explanation

Choice A reason: Limiting fluid intake is not an appropriate intervention for labyrinthitis. Adequate hydration is important for overall health and should be maintained.

Choice B reason: The correct answer is b because labyrinthitis can affect the vestibular system, leading to dizziness and vertigo. Monitoring the client’s cardinal fields of vision helps assess for nystagmus, which is a common symptom of vestibular disorders.

Choice C reason: Encouraging ambulation is not advisable for clients with labyrinthitis, as it can increase the risk of falls and injury due to dizziness and imbalance.

Choice D reason: Ensuring the room is brightly lit is not necessary for the management of labyrinthitis and may not provide any therapeutic benefit.

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A nurse is caring for a client who is suspected to have active laryngeal tuberculosis (TB). Which of the following actions should the nurse plan to take to safely care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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