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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View Related questions
Correct Answer is D
Explanation
Choice A reason:
“It is not necessary to tell the doctor about the herbal supplements I take.” This statement is incorrect. It is crucial to inform the doctor about all medications, including herbal supplements, as they can interact with prescription medications and cause adverse effects. Herbal supplements can strongly affect the body and may not work well with prescription medicines.
Choice B reason:
“I am less likely to experience an allergic reaction from medications I have taken before.” This statement is incorrect. Allergic reactions can occur even if the medication has been taken before without any issues. The immune system can develop sensitivities over time, and an allergic reaction can happen at any point.
Choice C reason:
“If a medication makes me feel nauseated, then I should stop taking it for 1 week.” This statement is incorrect. Stopping a medication without consulting a healthcare provider can be dangerous. It is important to discuss any side effects with a healthcare provider to determine the best course of action. Stopping a medication abruptly can lead to worsening of the condition or other complications.
Choice D reason:
“My medications could interact with foods that I eat.” This statement is correct. Certain foods can interact with medications and affect their absorption, effectiveness, or cause adverse effects. For example, grapefruit juice can interact with statins and increase the risk of side effects. It is important to be aware of potential food-drug interactions and follow the healthcare provider’s advice on medication administration.
Correct Answer is D
Explanation
Choice A Reason:
Informing the provider of the delay in obtaining the type and cross-match is important for keeping the healthcare team informed. However, this action should follow the immediate step of obtaining the type and cross-match to ensure the client has compatible blood available for surgery. Communication with the provider is crucial but secondary to addressing the immediate need.
Choice B Reason:
Documenting the incident in the client’s medical record is necessary for maintaining accurate records and ensuring continuity of care. However, this action should be performed after the immediate need for obtaining the type and cross-match is addressed. Accurate documentation is essential but not the first priority in this situation.
Choice C Reason:
Preparing an incident report for risk management is important for identifying and addressing potential system issues that led to the oversight. However, this action is not the immediate priority. The primary focus should be on obtaining the type and cross-match to ensure the client’s safety during surgery. Incident reporting can be done after the immediate needs are met.
Choice D Reason:
Obtaining the client’s type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery. This step directly addresses the immediate clinical need and prioritizes the client’s safety and readiness for surgery.