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 C
Explanation
Choice A Reason:
Moving quickly to a position in front of the client is not recommended. This action could result in both the nurse and the client falling, potentially causing injury to both parties.
Choice B Reason:
Remaining upright as the client falls toward them is incorrect. This action does not provide adequate support or control, increasing the risk of injury to the client.
Choice C Reason:
Allowing the client to slide down their outstretched leg is the correct action. This technique helps control the fall and minimizes the risk of injury by providing a controlled descent to the floor.
Choice D Reason:
Placing their arms around the client to prevent the fall is not advisable. This action can lead to both the nurse and the client falling, which could result in injuries.
Correct Answer is A
Explanation
Choice A reason:
A client who has new onset of dyspnea 24 hours after a total hip arthroplasty should be seen first. Dyspnea, or difficulty breathing, can be a sign of a serious complication such as a pulmonary embolism, which is a medical emergency. Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the legs or other parts of the body. This condition requires immediate assessment and intervention to prevent life-threatening consequences.
Choice B reason:
A client who has a urinary tract infection and low-grade fever is a concern, but it is not as urgent as the client with new onset dyspnea. Urinary tract infections (UTIs) are common and can be managed with antibiotics and supportive care. While a low-grade fever indicates an infection, it does not pose an immediate threat to the client’s life. The nurse should still address this client’s needs, but it can be done after attending to the more urgent case.
Choice C reason:
A client who has acute abdominal pain of 4 on a scale from 0 to 10 should be assessed, but it is not as critical as the client with new onset dyspnea. Acute abdominal pain can have various causes, some of which may require urgent attention, but a pain level of 4 indicates moderate pain. The nurse should evaluate this client to determine the cause of the pain and provide appropriate interventions, but it can be done after addressing the more urgent case.
Choice D reason:
A client who has pneumonia and an oxygen saturation of 96% is stable at the moment. Oxygen saturation levels above 95% are generally considered acceptable in pneumonia patients. While pneumonia requires monitoring and treatment, the client’s current oxygen saturation level indicates that they are not in immediate respiratory distress. The nurse should continue to monitor this client and provide necessary care, but it can be done after attending to the more urgent case.
