A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?
Have the client wear a surgical mask while being transported outside the room.
Wear a surgical mask while providing care for the client.
Restrict visitors from entering the client's room during hospitalization.
Initiate contact precautions for the client upon admission.
The Correct Answer is A
Rationale:
A. Having the client wear a surgical mask while being transported outside the room is essential to prevent the transmission of TB to others. This minimizes exposure to airborne droplets.
B. Wearing a surgical mask while providing care for the client is not sufficient for preventing TB transmission; an N95 respirator is required to protect healthcare workers from inhaling airborne particles.
C. While restricting visitors may help limit exposure, it is not the most effective preventive measure compared to ensuring that the client wears a mask when out of their room.
D. Initiating contact precautions is not necessary for TB, as it primarily requires airborne precautions. Airborne isolation precautions should be followed, including the use of N95 respirators for healthcare workers and appropriate ventilation.
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Correct Answer is D
Explanation
Rationale:
A. Providing interpretation services over the telephone is not effective for clients with hearing loss who may benefit more from in-person or visual communication.
B. Exaggerated lip movements can be distracting and may not aid understanding; clear and natural speech is more effective.
C. While providing written materials is helpful, ensuring the client can understand the material is key; using an appropriate reading level is essential but secondary to direct communication strategies.
D. Reducing environmental stimuli helps minimize distractions, making it easier for the client to focus on the nurse's speech or lip movements and improving overall communication.
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. Polyuria is not typically associated with immobility; instead, immobility can lead to urinary retention.
B. Contractures of the extremities occur due to prolonged immobility, leading to shortening of muscles and tendons.
C. Diarrhea is not a common complication of immobility; constipation is more frequently seen due to decreased mobility.
D. Crackles in the lungs can develop due to stasis of secretions and respiratory complications related to immobility.
E. Pressure ulcers develop from prolonged pressure on the skin due to immobility, especially over bony prominences.