A nurse is teaching a client who has tuberculosis about infection control with her family at home. Which of the following instructions should the nurse include?
"Wear a high-filtration mask at home when family members are nearby."
"Before coughing or sneezing, cover your mouth and nose with a tissue.
"Return to work after two consecutive sputum cultures are negative."
"Make sure family members wear masks whenever they are in the same room as you."
The Correct Answer is B
A. "Wear a high-filtration mask at home when family members are nearby.": Clients with TB do not need to wear high-filtration masks at home once effective treatment has begun, as transmission risk decreases rapidly. Home precautions focus more on cough hygiene and ventilation rather than continuous mask use inside the home.
B. "Before coughing or sneezing, cover your mouth and nose with a tissue.": Covering the mouth and nose prevents airborne spread of Mycobacterium tuberculosis by limiting droplet dispersion. This, combined with immediate disposal of tissues and hand hygiene, is essential for protecting household members.
C. "Return to work after two consecutive sputum cultures are negative.": Clearance for work is based primarily on sputum smears, clinical improvement, and provider guidance, not sputum cultures, which take weeks to result. Waiting for negative cultures is unnecessary for determining when a client is no longer infectious.
D. "Make sure family members wear masks whenever they are in the same room as you.": Family members generally do not need to wear masks once the client has started effective treatment for several weeks because infectivity significantly decreases. Emphasis is placed instead on good ventilation, cough etiquette, and adherence to medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Calcium gluconate: This medication is used to treat conditions such as hypocalcemia or magnesium toxicity and has no role in reversing opioid-induced respiratory depression. Its effects do not impact opioid receptors or respiratory drive.
B. Naloxone: Naloxone is an opioid antagonist that rapidly reverses opioid-induced respiratory depression by displacing opioids from receptor sites. It restores ventilation within minutes and is the primary treatment for acute opioid toxicity in postoperative settings.
C. Diphenhydramine: This antihistamine is used for allergic reactions or as a sedative but can worsen CNS depression. It offers no therapeutic benefit for treating respiratory depression caused by morphine.
D. Flumazenil: Flumazenil reverses benzodiazepine-induced sedation, not opioid effects. Administering flumazenil would not improve respiratory status in a client experiencing opioid-related complications.
Correct Answer is ["D","E","F"]
Explanation
A. Temperature: The client’s temperature is stable and within normal postoperative limits, and there are no signs in the assessment suggesting fever or infection as the primary concern. Reassessing temperature does not directly evaluate the effectiveness of interventions related to abdominal distention, pain, or bowel function.
B. Hematocrit: The hematocrit value is mildly low but expected after surgery and shows no indication of acute bleeding or fluid imbalance requiring reevaluation. Monitoring hematocrit will not provide information about the effectiveness of interventions for abdominal symptoms or pain management on postoperative day 3.
C. Urine output: The output is currently high (66.7\ mL/hr). While continuous monitoring is always necessary, the primary focus of re-evaluation after intervening for the GI issue is not the urine output.
D. Abdomen: The client has abdominal distention, hypoactive bowel sounds, and ongoing severe pain, indicating possible ileus or obstruction. Reassessing the abdomen allows the nurse to evaluate whether interventions are improving bowel motility and reducing gastrointestinal distress.
E. Pain rating: The client continues to experience severe pain despite medication, suggesting limited response to current interventions. Reassessing pain helps determine whether additional or alternative pain management measures are required and whether abdominal pathology is worsening.
F. Flatus: The presence or absence of flatus is a key indicator of returning bowel function following abdominal surgery. Reassessing flatus helps evaluate whether interventions are improving gastrointestinal motility and reducing the risk of postoperative ileus or obstruction.
G. Oxygen saturation: The client’s oxygen saturation is stable, and no respiratory issues are noted in the assessment. Reassessing oxygen saturation does not provide meaningful information about the effectiveness of interventions focused on abdominal symptoms and pain.
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