A nurse is providing care to a client who is immunocompromised.
Which of the following should the nurse identify as a possible source of infection?

Choice A rationale:

Airborne precautions should be initiated for clients with tuberculosis (TB) who have a productive cough. TB is transmitted through the airborne route when an infected individual coughs, sneezes, or talks, releasing infectious droplets into the air. Airborne precautions include the use of negative-pressure isolation rooms and N95 respirators for healthcare workers to prevent the spread of TB.

Choice B rationale:

Protective precautions are not typically used for clients with TB. Protective precautions are more commonly employed for clients with compromised immune systems to protect them from infection.

Choice C rationale:

Droplet precautions are not sufficient for clients with TB because TB is primarily transmitted via airborne particles, not droplets. Droplet precautions are used for diseases like influenza or meningitis, which are transmitted through larger respiratory droplets.

Choice D rationale:

Contact precautions are not appropriate for clients with TB because TB is primarily transmitted through the airborne route. Contact precautions are typically used for diseases that are transmitted through direct contact with the client or contaminated surfaces.

Clamp chest tube when client ambulates.Contraindicated. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition.The chest tube should be kept open and patent at all times, unless ordered by the provider for a specific reason. Report burning pain in chest to provider.Indicated.

Burning pain in the chest may indicate an infection, inflammation, or injury to the pleura or lung tissue.The provider should be notified of any changes in the client’s pain or discomfort.

Reinforce dressing around the tube as needed if it loosens.Indicated. The dressing around the chest tube should be kept dry and intact to prevent air leaks and infection.If the dressing becomes loose, wet, or soiled, it should be reinforced with sterile gauze and tape.

Strip the tubing twice daily to ensure patency.Contraindicated. Stripping or milking the tubing can cause increased negative pressure in the chest cavity, which can damage the lung tissue and impair gas exchange.The tubing should be assessed for kinks, clots, or obstructions, and gently tapped or repositioned if needed.

Maintain chest tube below the chest.Indicated.The chest tube should be kept below the level of the chest to facilitate drainage by gravity and prevent backflow of fluid into the pleural space.