Medical Surgical Tuberculosis #5

Question

The nurse is performing an admission assessment of a 26-year-old client with a preliminary diagnosis of tuberculosis. The nurse will provide a plan of care which includes which of these interventions? Select all the apply.

Answers

  1. Wear gloves and gown when only handling body fluids and bowel movements.
    • Rationale:

      This answer is not correct because gloves and an N95 respirator should be worn at all times when in the client’s room. TB requires that the client be placed in airborne precautions.

  2. Make sure the room is positive-pressured for positive airflow.
    • Rationale:

      This answer is not correct because the client will need to be placed in a room with negative pressure because TB is easily spread through the air.

  3. Wear an N95 respirator mask prior to entering the client's room.
    • Rationale:

      This answer is correct because an N95 respirator mask should be worn at all times when in contact with clients with suspected or confirmed TB. The N95 respirator is part of airborne precautions that must be taken with these clients.

  4. Administer the first round of tuberculosis medications.
    • Rationale:

      This answer is correct because the nurse should plan on administering the first phase of TB medications which includes isoniazid, rifampin, pyrazinamide, and ethambutol.

  5. Place a “Contact Precautionsâ€ sign on the client's door.
    • Rationale:

      This answer is not correct because the client will be placed in airborne precautions as opposed to contact precautions. With contact precautions, a gown and gloves are required, however with airborne precautions gloves and an N95 respirator are required when in the client’s room.

Overview

The focus of this question is interventions included in the care of a client with suspected tuberculosis (TB). TB is a highly contagious bacterial illness that requires the client to be placed in airborne precautions in a room with negative pressure in order to prevent spread of the disease.

Explanation

Learning Outcomes

Tuberculosis (TB) is caused by infection with the bacteria mycobacterium tuberculosis. The bacteria is transmitted via the airborne route when a client coughs, sneezes, or speaks loudly. Clients with suspected or confirmed tuberculosis infection should immediately be placed in airborne isolation precautions in a negative pressure room. It is also essential to begin combination therapy with antitubercular antibiotics as soon as possible.

Test Taking Tip

Isolation precautions are an important aspect of the safety and infection control client needs category of NCLEX.

Video Rationale