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

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

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

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

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

Answer and Explanation

The Correct Answer is A

A. Place the client in a private room with a special ventilation system.
The primary method to prevent the transmission of tuberculosis is to place the client in a negative pressure room with adequate ventilation. This helps to reduce the risk of airborne transmission of the Mycobacterium tuberculosis bacteria.

B. Modify the protocol for donning and removing personal protective equipment before entering or leaving the client’s room:
Standard precautions should be followed, but the primary emphasis is on airborne precautions due to the potential for airborne transmission of TB. Modifications to donning and removing PPE are not the main focus.

C. Have staff and visitors wear gowns, masks, and gloves while in the client’s room:
Airborne precautions are more specific for suspected active tuberculosis. While gowns, masks, and gloves may be used for other infectious diseases, the key precaution for TB is a private room with negative pressure ventilation.

D. Assign the client to a room with other clients who require droplet precautions:
Tuberculosis is primarily transmitted through airborne particles, not droplets. Placing the client in a room with droplet precautions is not sufficient to prevent the spread of tuberculosis.

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Correct Answer is A

Explanation

A. “I have not received any of my medications today.”
The statement "I have not received any of my medications today" requires follow-up from the nurse because it indicates a potential issue with the client's medication administration. It's important to ensure that the client receives the prescribed medications in a timely manner.

B. “Do you know when I will be going home?”
This is a question about the discharge plan and does not indicate an immediate issue that requires follow-up.

C. “I do not know how to make the remote control work.”
While it's a statement about the client's understanding of the remote control, it is not an urgent matter that requires immediate attention.

D. “My dressing was changed earlier this morning.”
This statement indicates that a care task (dressing change) has been completed and does not suggest a problem that requires urgent follow-up.

A. The patient may need suctioning B. The patient extubated himself C. The ventilator tubing may be disconnected. D. The cuff at the end of the endotracheal tube is deflated.

Correct Answer is A

Explanation

A. The patient may need suctioning:
A high-pressure alarm indicates increased resistance to airflow, which could be caused by secretions or mucus in the airways. Suctioning is the appropriate intervention to clear the airways of excess secretions, reducing airway resistance and preventing the high-pressure alarm.

B. The patient extubated himself:
If the patient extubates himself (removes the endotracheal tube), this may result in a low-pressure alarm, not a high-pressure alarm. The low-pressure alarm is triggered when there is a loss of pressure within the ventilator circuit due to disconnection or extubation.

C. The ventilator tubing may be disconnected:
If the ventilator tubing is disconnected, it is more likely to trigger a low-pressure alarm, indicating a loss of pressure in the ventilator circuit. This is not the primary cause of increased resistance seen with a high-pressure alarm.

D. The cuff at the end of the endotracheal tube is deflated:
A deflated cuff can lead to air leakage around the endotracheal tube but is not the primary cause of increased airway resistance seen with a high-pressure alarm. It may cause a low-pressure alarm if cuff pressure is monitored.

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A nurse is preparing for the admission of 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

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Correct Answer is A

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