Influenza B

A nurse is caring for a 45-year-old female client in the medical-surgical unit who was admitted with a 2-day history of headache, muscle aches, fever, sore throat, and fatigue, and a throat culture positive for influenza B.

Based on the information in the EHR, which of the following actions should the nurse take? Select all that apply.

Choice A rationale

An absolute neutrophil count (ANC) less than 1,000/mm³ indicates neutropenia, which significantly increases the risk of infection. Limiting visitors to healthy adults minimizes exposure to pathogens that could be carried by individuals who are ill or immunocompromised, thereby reducing the risk of opportunistic infections.

Choice B rationale

Taking a rectal temperature is contraindicated in neutropenic clients due to the risk of introducing bacteria from the rectum into the bloodstream, which could lead to bacteremia or sepsis. Oral or axillary temperatures are preferred methods for temperature assessment in immunocompromised individuals to prevent mucosal trauma.

Choice C rationale

Increasing raw produce in the client's diet is contraindicated in neutropenic clients. Uncooked fruits and vegetables can harbor bacteria and fungi that, while usually harmless to individuals with intact immune systems, can cause severe infections in immunocompromised patients due to compromised gut mucosal barriers.

Choice D rationale

Instructing the client to floss his teeth daily is contraindicated in severe neutropenia. Flossing can cause micro-abrasions and bleeding of the gingiva, creating entry points for oral bacteria into the bloodstream, which can lead to systemic infections in a client with a severely compromised immune system.

Choice A rationale

While monitoring clients is important, placing a client with active tuberculosis in a room within view of the nurses' station does not address the fundamental need for infection control. Tuberculosis is an airborne disease requiring specific environmental controls to prevent transmission, which this choice does not provide.

Choice B rationale

A room with air exhaust directly to the outdoor environment, often called a negative pressure room or airborne infection isolation room (AIIR), is essential for clients with active tuberculosis. This design prevents airborne mycobacteria from circulating within the healthcare facility, directing them outside to reduce the risk of transmission to others.

Choice C rationale

Placing a client with active tuberculosis in the ICU is generally unnecessary unless their clinical condition warrants critical care, such as respiratory failure. The primary concern for tuberculosis is airborne isolation, which can be achieved on a regular medical-surgical unit with appropriate room design and ventilation, not necessarily an ICU level of care.

Choice D rationale

Cohabiting a client with active tuberculosis with another nonsurgical client is highly inappropriate and unsafe. Tuberculosis is transmitted via airborne particles, and co-rooming would expose the other client to a significant risk of infection. Dedicated isolation is paramount for preventing nosocomial spread.