A nurse is admitting a client who has tuberculosis. What transmission-based precautions should the nurse initiate?

Correct Answer: C

Rationale: In the context of admitting a client with tuberculosis, the appropriate transmission-based precautions that the nurse should initiate are airborne precautions. Tuberculosis is primarily spread through the air when an infected individual coughs, sneezes, or talks, releasing droplet nuclei containing the bacteria. Airborne precautions are necessary to prevent the transmission of these infectious droplet nuclei to others. Option A, droplet precautions, are used for diseases that are transmitted through large respiratory droplets that do not remain suspended in the air for long periods, like influenza. Contact precautions (Option B) are used for diseases that are spread by direct or indirect contact with the patient or their environment, such as MRSA. Protective precautions (Option D) are not a standard transmission-based precaution category. Educationally, understanding the rationale behind selecting the correct transmission-based precautions for specific infectious diseases is crucial for nurses to provide safe and effective care, prevent the spread of infections within healthcare settings, and protect both patients and healthcare workers. By knowing the modes of transmission and appropriate precautions for different diseases, nurses can play a key role in infection control and maintaining a safe healthcare environment.

Correct Answer: D

Rationale: In this scenario, the nurse should choose option D, which is to keep the nursing diagnosis in the plan of care the same since the risk factors are still present. This is the best action because even though the skin integrity has not been impaired after one week, the client is still at risk due to the continued need for bedrest. Choosing option A to remove the nursing diagnosis is incorrect because the risk factors that led to the initial diagnosis are still present, so vigilance is necessary. Option B, changing the diagnosis to impaired mobility, is not appropriate as the primary concern is the risk of impaired skin integrity due to prolonged bedrest. Option C, modifying the diagnosis to impaired skin integrity, is unnecessary since the skin integrity has not been compromised yet, but the risk remains. Educationally, this scenario highlights the importance of ongoing assessment and evaluation in nursing care. It emphasizes the need to consider the underlying risk factors that led to the initial diagnosis and to continue monitoring the client's condition to provide proactive care and prevent potential complications. It also underscores the significance of critical thinking and clinical judgment in nursing practice.

Correct Answer: D

Rationale: In understanding the causes of pressure ulcers, it is crucial to recognize the role of perfusion in preventing these skin injuries. Adequate perfusion, which refers to the circulation of blood to tissues, is essential for maintaining the health of the skin and preventing the development of pressure ulcers. When tissues do not receive enough blood flow, they are more susceptible to damage from prolonged pressure, leading to the formation of pressure ulcers. Immobility, poor nutrition, and moisture are all well-established risk factors for pressure ulcers. Immobility can result in prolonged pressure on certain areas of the body, reducing blood flow and causing tissue damage. Poor nutrition can impair the body's ability to repair and maintain healthy skin, making individuals more vulnerable to pressure ulcers. Moisture, especially when combined with pressure, can further increase the risk of skin breakdown and ulcer formation. In an educational context, understanding the causes of pressure ulcers is essential for healthcare professionals, caregivers, and patients themselves. By recognizing the significance of factors such as immobility, poor nutrition, moisture, and perfusion, individuals can implement preventive measures to reduce the incidence of pressure ulcers. Educating patients on the importance of mobility, proper nutrition, skin care, and circulation can empower them to take proactive steps in maintaining skin integrity and overall well-being.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B: a client that recently traveled and developed a fever with cough. This client should be placed in isolation for airborne precautions due to the potential risk of carrying an airborne infectious disease such as tuberculosis or influenza. Option A, a high school wrestling champion with a rash, does not indicate a need for airborne precautions as rashes are typically not transmitted through the air. Option C, a client with an unknown skin infection, would not require airborne precautions unless the skin infection is associated with an airborne pathogen, which is not mentioned in the scenario. Option D, a client with heart palpitations, does not require airborne precautions as heart palpitations are not indicative of an airborne infectious disease. In an educational context, understanding the different types of precautions in healthcare settings is crucial for preventing the spread of infections. Airborne precautions are specifically used for diseases that are transmitted through the air via droplet nuclei. It is important for healthcare providers to correctly identify which clients require airborne precautions to ensure the safety of both patients and healthcare workers.

Correct Answer: D

Rationale: In caring for a client with Rheumatoid Arthritis (RA), the best goal for pain control is for the client to have pain less than 8/10 throughout the day (Option D). This goal is considered appropriate because RA is a chronic condition characterized by persistent pain and inflammation. Achieving pain levels below 8/10 can significantly improve the client's quality of life, mobility, and overall well-being. Option A, focusing on healthy meals and hydration, although important for overall health and managing RA symptoms, does not directly address the immediate goal of pain control. Option B, having pain throughout the entire day, is not a suitable goal as it does not aim for pain reduction. Option C, having pain less than 3/10 for most of the day, may be too ambitious for some clients with RA and may not be realistic or sustainable in the long term. In an educational context, understanding the importance of setting realistic and achievable goals for pain management in clients with RA is crucial. Educators should emphasize the individualized nature of pain management goals and the need to balance aspirations for pain reduction with the client's unique circumstances and limitations. By focusing on realistic and attainable goals, healthcare providers can better support clients in managing their pain effectively and improving their overall quality of life.