A charge nurse has four new clients arriving on the unit for admission. Which of the following clients should the nurse place in airborne precautions?
A client who has tuberculosis.
A client who has pneumonia.
A client who has shigella.
A client who has strep throat.
The Correct Answer is A
Choice A Reason:
Tuberculosis (TB) is a highly contagious bacterial infection that primarily affects the lungs and is spread through airborne particles. When a person with active TB coughs, sneezes, or talks, they release tiny droplets containing the bacteria into the air, which can be inhaled by others1. Therefore, placing a client with TB in airborne precautions is essential to prevent the spread of the infection. This involves using a negative pressure room and requiring healthcare workers to wear N95 respirators or higher-level protection.
Choice B Reason:
Pneumonia is an infection that inflames the air sacs in one or both lungs, which can fill with fluid or pus. While pneumonia can be caused by bacteria, viruses, or fungi, it is typically spread through respiratory droplets rather than airborne particles. Therefore, droplet precautions, rather than airborne precautions, are usually sufficient for managing clients with pneumonia. This includes wearing masks and maintaining a safe distance from the infected person.
Choice C Reason:
Shigella is a bacterial infection that primarily affects the intestines and is spread through the fecal-oral route. It is not transmitted through the air, so airborne precautions are not necessary. Instead, contact precautions are recommended to prevent the spread of Shigella, which involves wearing gloves and gowns when handling the patient or their environment and practicing good hand hygiene.
Choice D Reason:
Strep throat is a bacterial infection caused by group A Streptococcus. It is spread through respiratory droplets when an infected person coughs or sneezes. Similar to pneumonia, droplet precautions are sufficient for managing clients with strep throat. This includes wearing masks and maintaining a safe distance from the infected person to prevent the spread of the bacteria.
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Correct Answer is D
Explanation
Choice A Reason:
The National League for Nursing (NLN) is an organization that focuses on nursing education and the development of nurse educators. While it plays a significant role in advancing the quality of nursing education, it does not define the nursing scope of practice. The NLN provides resources, professional development, and accreditation for nursing programs, but the legal scope of practice is determined by state laws and regulations.
Choice B Reason:
The Joint Commission is an independent, non-profit organization that accredits and certifies healthcare organizations and programs in the United States. Its primary role is to ensure that healthcare organizations meet certain performance standards to provide safe and effective care. While the Joint Commission sets standards for healthcare quality and safety, it does not define the nursing scope of practice. Its focus is on organizational accreditation rather than individual professional practice.
Choice C Reason:
The Patients Bill of Rights is a document that outlines the rights and responsibilities of patients within the healthcare system. It aims to ensure that patients receive fair and respectful treatment and have a voice in their care decisions. Although it is important for protecting patient rights, it does not define the nursing scope of practice. The Patients Bill of Rights addresses patient care from a consumer perspective rather than a professional regulatory standpoint.
Choice D Reason:
State-based Nurse Practice Acts are laws enacted by state legislatures that define the scope of practice for nurses within that state. These acts outline the legal parameters for nursing practice, including what tasks and responsibilities nurses are authorized to perform. They are designed to protect public health and safety by ensuring that nurses provide care within their level of competence and training. The Nurse Practice Acts are the primary source for defining the nursing scope of practice and are enforced by state boards of nursing.
Correct Answer is B
Explanation
Choice A reason:
Attaching the restraints using a quick-release tie is essential for ensuring the safety of the client and the healthcare staff. A quick-release tie allows for the rapid removal of the restraints in case of an emergency, such as a fire or a sudden change in the client’s condition. This method is recommended by healthcare guidelines to ensure that restraints can be removed swiftly and safely.
Choice B reason:
Contacting the provider for a PRN (as needed) prescription for restraints is a necessary step to ensure that the use of restraints is authorized and documented. Restraints should only be used when absolutely necessary and with proper authorization to prevent misuse and to protect the client’s rights. This step ensures that the decision to use restraints is made with careful consideration and in accordance with legal and ethical standards.
Choice C reason:
Securing the restraints to a side rail on the client’s bed is not recommended. This practice can pose a significant risk to the client, as it can lead to injury if the client attempts to move or if the side rail is raised or lowered. Restraints should be secured to a part of the bed frame that does not move, such as the bed frame itself, to ensure the client’s safety.
Choice D reason:
Leaving enough room to fit three fingers between the restraints and the client’s wrist is incorrect. The correct practice is to leave enough room to fit two fingers between the restraints and the client’s wrist. This ensures that the restraints are not too tight, which could cause circulation problems or skin damage, and not too loose, which could allow the client to remove them.