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 ["B","C","D"]
Explanation
Choice A Reason:
When providing client education about the medication, the nurse focuses on informing the client about the purpose, dosage, and potential side effects of the medication. This step is crucial for ensuring that the client understands their treatment plan and can adhere to it properly. However, this is not the appropriate time to compare the medication administration record (MAR) against the medication container. The comparison should be done during the actual medication administration process to prevent errors.
Choice B Reason:
At the client’s bedside before administering the medication, the nurse should compare the MAR against the medication container. This step is part of the “three checks” process, which helps ensure that the correct medication is given to the right patient at the right time. By verifying the medication at the bedside, the nurse can catch any discrepancies and prevent potential medication errors.
Choice C Reason:
Before selecting the medication container, the nurse should compare the MAR against the medication container. This is the first of the “three checks” and is essential for ensuring that the correct medication is selected from the storage area. This step helps prevent errors that could occur if the wrong medication is chosen.
Choice D Reason:
While removing medication from the container, the nurse should again compare the MAR against the medication container. This is the second of the “three checks” and serves as an additional safeguard to ensure that the correct medication is being prepared for administration. This step helps catch any errors that might have been missed during the initial selection.
Choice E Reason:
When documenting the medication administration, the nurse records the details of the medication given, including the time, dosage, and any observations. While accurate documentation is crucial for maintaining a complete medical record, this is not the appropriate time to compare the MAR against the medication container. The comparison should be done during the medication administration process to ensure accuracy.
Correct Answer is D
Explanation
Choice A Reason:
Leaving a transfer belt in place until the client returns from radiology is not recommended. The transfer belt is used to assist in moving the client safely, but it should be removed once the client is securely seated in the wheelchair to prevent discomfort or potential injury.
Choice B Reason:
Positioning the client so their weight is shifted forward is not a standard practice for transferring a client to a wheelchair. Proper positioning involves ensuring the client is seated comfortably and securely, with their weight evenly distributed to prevent falls or injuries.
Choice C Reason:
Lowering the footplates before transferring the client from the bed is incorrect. The footplates should be raised to allow the client to safely transfer from the bed to the wheelchair without tripping or getting their feet caught.
Choice D Reason:
Backing the wheelchair into the elevator is the correct action. This ensures that the client enters the elevator facing forward, which is safer and more comfortable for the client. It also allows the nurse to maintain better control of the wheelchair during the transition.