The nurse recognizes the assessment data which best indicates that the client diagnosed with asthma is achieving good control with the prescribed medication regimen is when:

Choice A reason:

Initiating droplet precautions is not sufficient for a client presenting with symptoms such as coughing up blood, productive cough, and night sweats. These symptoms are indicative of possible tuberculosis (TB), which is an airborne disease. Droplet precautions are used for infections spread through large respiratory droplets, such as influenza or pertussis, but not for TB.

Choice B reason:

Considering standard precautions to be sufficient is incorrect. Standard precautions are the basic level of infection control that should be used in the care of all patients to prevent the spread of infections. However, for a client with symptoms suggestive of TB, additional airborne precautions are necessary to prevent the spread of the disease.

Choice C reason:

Transferring the client to a positive pressure room is inappropriate. Positive pressure rooms are designed to keep contaminants out and are used for protecting immunocompromised patients from infections. For a client with suspected TB, a negative pressure room is required to prevent the spread of infectious particles to other areas.

Choice D reason:

Initiating airborne precautions is the correct intervention. Airborne precautions are necessary for diseases that are transmitted through smaller respiratory droplets that can remain suspended in the air and be inhaled by others. Tuberculosis is one such disease, and initiating airborne precautions helps to prevent the spread of the infection to healthcare workers and other patients.

Notify the surgeon of the blood pressure: While notifying the surgeon of the elevated blood pressure is important, it is not the immediate first action. The nurse should first address the elevated blood pressure by administering the prescribed antihypertensive medication. Once the medication is given, the nurse can then notify the surgeon if the blood pressure remains elevated or if there are any other concerns.

Choice B reason:

Document the blood pressure on the pre-op checklist: Documentation is crucial for maintaining accurate medical records, but it is not the first action in this scenario. The nurse should prioritize administering the antihypertensive medication to manage the client’s elevated blood pressure. After addressing the immediate concern, the nurse can document the blood pressure and any interventions taken.

Choice C reason:

Have the client relax and take deep breaths: Encouraging the client to relax and take deep breaths can help lower blood pressure temporarily, but it is not a substitute for administering the prescribed antihypertensive medication. This action can be taken in conjunction with medication administration but should not be the first or only action.

Choice D reason:

Administer the antihypertensive medication: Administering the antihypertensive medication is the correct first action. The client’s blood pressure is significantly elevated at 174/88, and the medication is necessary to manage this condition. According to perioperative guidelines, most antihypertensive medications should be continued until surgery to prevent complications such as hypertensive crises. Administering the medication will help stabilize the client’s blood pressure and reduce the risk of perioperative complications.