A nurse is preparing for the admission of a client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?

Have staff and visitors wear gowns, masks, and gloves while in the client's room.

Modify the protocol for donning and removing personal protective equipment before entering or leaving the client's room.

Assign the client to a room with other clients who require droplet precautions.

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

Answer and Explanation

The Correct Answer is D

A. Gowns and gloves are not required for TB precautions; a mask is necessary to protect against airborne transmission.
B. Standard protocols for personal protective equipment (PPE) should be followed, but they do not specifically address the need for specialized precautions in TB care.
C. Clients with TB should not be placed in a room with others, even those requiring droplet precautions, due to the risk of airborne transmission.
D. A private room with a special ventilation system, such as negative pressure, is essential for isolating clients with active TB to prevent airborne transmission.

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Correct Answer is A

Explanation

A. Bladder distension is a common trigger for autonomic dysreflexia in individuals with spinal cord injuries above T-6. It is crucial to manage bladder function to prevent this potentially life-threatening condition.

B. Elevated blood pressure is a sign of autonomic dysreflexia rather than a predisposing factor. Identifying the trigger, such as bladder distension, is essential before addressing the elevated blood pressure.

C. Nasal congestion is not typically associated with autonomic dysreflexia. While it might be uncomfortable, it is not a common trigger for this condition.

D. A severe headache can be a symptom of autonomic dysreflexia, but identifying the underlying cause or trigger, such as bladder distension, is essential for proper management.

A. Obtain a prescription for pain medication. B. Discharge the client. C. Remove both of the elastic bandages from the leg. D. Obtain a prescription for the appropriate anti-venom.

Correct Answer is C

Explanation

A. While pain management may be necessary, it is not the priority in the initial management of a snake bite. The focus should be on addressing the potential spread of venom.

B. Discharging the client is not appropriate as the client requires immediate medical evaluation and treatment due to the venomous snake bite.

C. Removing the elastic bandages is crucial as they can impede blood flow and potentially exacerbate the spread of venom. Elastic bandages should not be used to constrict the limb; proper medical treatment is needed.

D. Obtaining a prescription for anti-venom is important but should be done after initial assessment and treatment of the snake bite. Removing constrictive bandages is the immediate action to take to manage the bite effectively.

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A nurse is preparing for the admission of a client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

Correct Answer is A

Explanation

A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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