The nurse is assessing a newly admitted client whose chief complaint is "coughing up blood" and whose recent history includes a productive cough and night sweats. What is the nurse's priority intervention?

Initiate droplet precautions

Initiate airborne precautions

Place the client in a positive pressure room

Initiate neutropenic precautions

Answer and Explanation

The Correct Answer is B

B. Airborne precautions are used for diseases that can be transmitted through tiny respiratory droplets that remain in the air for extended periods. Examples include tuberculosis and measles. Given the symptom of coughing up blood and the possibility of an infectious respiratory disease, initiating airborne precautions could be warranted.
A. Droplet precautions are typically implemented for diseases that spread through respiratory droplets, such as influenza or pertussis. However, coughing up blood suggests a more serious condition that may not be adequately addressed by droplet precautions alone.
C. Positive pressure rooms are typically used in healthcare settings to prevent outside air from entering the room, thus reducing the risk of airborne contaminants. While this measure can be beneficial for certain conditions, such as those requiring airborne precautions, it may not be the priority intervention.
D. Neutropenic precautions are implemented for patients with compromised immune systems, particularly those with low white blood cell counts (neutropenia). While this precaution is important for protecting immunocompromised patients from infections, it may not be the priority intervention.

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Correct Answer is B

Explanation

B. This is often a red flag that the client may not be free to act or speak on their own behalf, which is a common situation among victims of human trafficking.
A. A non-working cell phone alone may not be sufficient evidence to conclusively suspect human trafficking, as there could be various reasons for a phone not working.
C. Human traffickers often exploit victims by transporting them across state or international borders under false pretenses, such as offering a vacation or job opportunity. However, it's crucial to gather more information and assess the client's situation further before jumping to conclusions.
D. Language diversity is common in healthcare settings and may not always be indicative of trafficking.

A. "The police will want to interview you." B. "I will call your spouse." C. "We'll have to take photographs of those wounds." D. "You are safe now."

Correct Answer is D

Explanation

D. This statement prioritizes the client's immediate emotional needs by providing reassurance, validation, and a sense of safety in a traumatic situation. It acknowledges the client's distress and communicates empathy and support, which are essential for building trust and rapport and facilitating the client's emotional healing process.
A. The client may feel overwhelmed by the prospect of speaking to the police at that moment, and it may not be the most therapeutic statement to prioritize.
B. Contacting the client's spouse may provide emotional support and assistance, but it may not be the priority therapeutic statement in this situation.
C. The client may already be feeling vulnerable and exposed, and discussing the need for photographs may exacerbate feelings of distress or discomfort.

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The nurse is assessing a newly admitted client whose chief complaint is "coughing up blood" and whose recent history includes a productive cough and night sweats. What is the nurse's priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who is malnourished and appears exhausted. What data would cause the nurse to suspect the client is a victim of human trafficking? The client :

Correct Answer is B

Explanation

A client who has just been raped arrives at the Emergency Room. The client is crying, pacing and cursing their attacker. Which is the priority therapeutic statement for the nurse to make?

Correct Answer is D

Explanation

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