The nurse is caring for a patient diagnosed with tuberculosis in a hospital setting and must initiate airborne precautions. Which of the following is true related to airborne precautions?

Choice A reason: Hypertension is defined by elevated blood pressure, not an irregular heart rate. An irregular pattern at 72 bpm suggests a rhythm abnormality, not a pressure issue. Hypertension affects vascular resistance, not cardiac rhythm directly, making this incorrect for the observed finding, per cardiovascular physiology.

Choice B reason: A dysrhythmia is indicated by an irregular heart rate pattern at 72 bpm, as it reflects abnormal electrical conduction, such as atrial fibrillation or premature beats. Notifying the provider is appropriate, as dysrhythmias may impair cardiac output or indicate underlying pathology, requiring prompt evaluation, per cardiac monitoring protocols.

Choice C reason: Tachycardia is a heart rate above 100 bpm, not applicable to 72 bpm. The irregularity, not speed, is the concern. Tachycardia involves rapid but often regular rhythms, whereas this finding suggests a dysrhythmia, making this choice incorrect for the described clinical presentation, per cardiac assessment.

Choice D reason: Bradycardia is a heart rate below 60 bpm, not matching 72 bpm. The irregular pattern points to a dysrhythmia, not a slow rate. Bradycardia affects heart rate frequency, not rhythm irregularity, making this irrelevant to the finding, which requires rhythm-focused intervention, per cardiac physiology.

Choice A reason: Donning sterile gloves is unnecessary for abdominal assessment, as it requires clean gloves to prevent infection. Sterile gloves are used for invasive procedures, not palpation or auscultation. This action is irrelevant to preparing for palpation and wastes resources, per infection control and assessment protocols.

Choice B reason: Elevating the patient’s head may relax abdominal muscles but is not required before palpation. Auscultation precedes palpation to avoid altering bowel sounds by pressure. Elevating the head does not address the need for accurate bowel sound assessment, making it less critical, per abdominal examination sequence.

Choice C reason: Percussing all four quadrants follows auscultation and inspection, not precedes palpation. Percussion assesses organ size or fluid but may disrupt bowel sounds if done before auscultation. Auscultation is prioritized to capture unaltered sounds, ensuring a systematic abdominal assessment, per clinical examination guidelines.

Choice D reason: Auscultating bowel sounds before palpation is essential, as palpation may alter peristalsis, leading to inaccurate findings. Listening for hypoactive or hyperactive sounds identifies abnormalities like obstruction, guiding further assessment. This sequence preserves diagnostic accuracy, aligning with systematic abdominal examination protocols.