A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?
Assign the client to a room with other clients who require droplet precautions.
Modify the protocol for donning and removing personal protective equipment before entering or leaving the client's room.
Have staff and visitors wear gowns, masks, and gloves while in the client's room.
Place the client in a private room with a special ventilation system.
The Correct Answer is D
Rationale:
A. Clients with active tuberculosis should not be placed in a room with other clients, even if they require droplet precautions, as TB requires airborne precautions.
B. While PPE protocols are important, the most critical precaution for TB is ensuring the client is in the correct environment to prevent airborne transmission.
C. Wearing gowns, masks, and gloves is important, but the most essential measure is the room's ventilation system.
D. Active tuberculosis is an airborne infectious disease, so the client should be placed in a private room with a negative pressure ventilation system to prevent the spread of the bacteria through the air.
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Correct Answer is A
Explanation
Rationale:
A. The primary criterion for removing restraints is that the client must be calm and cooperative, indicating that the immediate safety concern has been addressed.
B. Verbalizing remorse is not a requirement for removing restraints; the focus is on the client's behavior and cooperation.
C. The provider does not need to be present for the nurse to assess the client's readiness for removal of restraints, although provider orders and assessments are important.
D. Simply verbalizing anger does not indicate that the restraints can be removed; the client must demonstrate appropriate behavior and cooperation.
Correct Answer is B
Explanation
Rationale:
A. Offering reassurance without addressing the client's immediate concerns may minimize the severity of the situation and delay necessary interventions.
B. Asking the client about the lethality of their plan is crucial for assessing the level of risk and determining the urgency of the intervention required. This information is essential for planning appropriate care and ensuring the client's safety.
C. Allowing the client to be alone is not appropriate when they have expressed suicidal intent, as this could increase the risk of self-harm.
D. Encouraging the client to focus on the positive aspects of life may be part of long-term therapy, but in the acute phase, the priority is to assess and address the immediate risk of suicide.