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2012-04-15 20:18:40

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  1. Airborne Transmission–Based Precautions (SecondTier of CDC Guidelines for Infection Control)Infections caused by organisms remain suspended in the air for prolonged periods oftime. Examples of infections that can be transmitted by airborne means include tuberculosis,measles (rubeola), chicken pox (varicella), and disseminated zoster (shingles).Nursing precautions for managing the client with an infection that can be spread byairborne means include. Placing the client in a private room with negative airflow (and with the doorremaining closed). Equipping persons entering the room with a HEPA mask or an N-95 mask. Lighting the room with ultraviolet light. Transporting the client only when essential. Fitting the client with a surgical mask when being transportedInfections are spread in several different ways. The sections that follow explain thesemethods of transmission and how the nurse can help to prevent the spread of germs.

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    72. (A) Client need: safe, effective care environment; subcategory:safety and infection control; content area: pediatricsRATIONALE(A) This is the appropriate response. Consulting the infectioncontrol nurse for alteratives for patient placement is best. (B) The uninfected child could become infected because this disease canbe transmitted through airborne droplets. (C) The child can becomeinfected with TB through airborne droplets. (D) The bestchoice would be to consult someone for placement before refusingto accept a child for admission.
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  3. Pulmonary TuberculosisDescription1. Pulmonary tuberculosis is an acute or chronic infectioncaused by the tubercle bacillus organism that leads to inflammationand formation of a permanent nodule containingthe tubercle bacillus.2. The person who has been infected harbors the bacillus forlife. It is dormant unless it becomes active during physicalor emotional stress.3. The nodules become fibrosed, and the area becomes calcifiedand can be identified by x-ray.4. The incidence of TB is currently increasing, and a drugresistantstrain is becoming a problem.5. High incidence in individuals with AIDS; the homeless; andothers living in crowded, poorly ventilated conditions.6. Transmission of the organism is by airborne droplets.7. Causes:A. Exposure to airborne droplets containing the tuberclebacillus from infected personB. Inhalation of airborne droplets containing tuberclebacilli194 Clinical Specialties: Content Reviews and Tests8. Factors contributing to activation of infectionA. Uncontrolled diabetes mellitusB. Hodgkin’s diseaseC. LeukemiaD. Treatment with corticosteroidsE. Immunosuppressive conditions such as AIDSF. Silicosi
  4. AssessmentSUBJECTIVE1. Early phase may be asymptomatic2. Fatigue3. Weakness4. Weight loss5. Anorexia6. Night sweats7. Low-grade fever8. Cough with micropurulent sputum9. Occasional hemoptysis (coughing up of blood from thelungs)10. Chest pains11. Anxiety, fear of public rejection
  5. OBJECTIVE1. Productive cough with micropurulent sputum2. Elevated afternoon temperature3. Positive chest x-ray4. Positive sputum for acid-fast bacilli5. Presence of hemoptysis6. Positive tuberculin testDIAGNOSTIC TESTS AND METHODS1. History of tuberculin exposure2. Physical examination3. Chest x-ray4. Tuberculin test5. Sputum smears and cultures6. Auscultation of chest7. Chest percussion
  6. Planning1. Safe, effective care environmentA. Prevent avoidable injury and/or infection.B. Assess appetite and maintain adequate nutritional status.C. Increase client’s and family’s knowledge of diseaseprocess, diagnostic procedures, and treatment.2. Psychological integrityA. Maintain effective airway clearance and gas exchange.B. Increase comfort.3. Psychosocial integrityA. Reduce anxiety.4. Health promotion and maintenanceA. Increase client’s and family’s knowledge of prevention,home care, and follow-up.
  7. Implementation1. Assess, record, and report signs and symptoms and reactionsto treatment.2. Isolate client in quiet, well-ventilated room during infectiveperiod.3. Assist with comfort measures.4. Assess respirations, breath sounds, and vital signs.5. Instruct client to cough, sneeze, or laugh into tissue.6. Instruct client to dispose of tissues in receptacle providedfor this purpose.7. Instruct client to wear mask when outside of room.8. Instruct staff and visitors to wear masks (recommendedby Occupational Health and Safety Administration).9. Encourage rest.10. Encourage client to eat well-balanced meals.11. If anorexic, encourage client to eat small meals more frequently.12. Record weight weekly.13. Observe, report, and record hemoptysis.14. Administer antituberculosis drugs as ordered.15. Explain need for taking medications (combinations of 2or 3) as ordered to prevent resistant strains.16. Watch for drug side effects—isoniazid sometimes leads tohepatitis or peripheral neuritis.17. Monitor aspartate transaminase (AST) and alaninetransaminase (ALT) levels.18. Give pyridoxine (vitamin B6) as ordered for peripheralneuritis.19. Use of ethambutol may cause optic neuritis (drug willprobably be discontinued).20. Use of rifampin may cause hepatitis and purpura.21. Instruct client and family regarding disease process, diagnosticprocedures, treatment, prevention, home care, andfollow-up. Include teaching on:A. Reporting side effects of medications immediatelyB. Importance of regular follow-up examinationsC. Reporting signs and symptoms of recurring TBD. Need for long-term treatmentE. Persons exposed to infected clients receiving tuberculintests and, if ordered, chest x-rays and prophylacticisoniazid
  8. Evaluation1. Reports increased comfort, decreased anxiety2. Shows no evidence of hemoptysis3. Maintains adequate nutrition4. Reports absence of cough and sputum5. Maintains effective airway clearance6. Negative sputum culture7. Demonstrates understanding of disease process, mode oftransmission, diagnostic procedures, treatment (longterm), home care, and need for follow-up
  9. 179. A client is receiving rifampin (Rifadin) po for treatmentof tuberculosis. The nurse should instruct theclient on which of the following?A. Avoid taking with milk.B. Avoid taking with alcohol.CHAPTER 5—Medical-Surgical Nursing: Content Review and Test 345C. Avoid breaking capsule.D. Avoid taking on an empty stomach.
    179. (B) Client need: physiological integrity; subcategory: pharmacologicaland parenteral therapies; content area: med/surgRATIONALE(A) This is incorrect because the capsule can be emptied andmixed with fluids or food if needed. (B) Alcohol increases therisk of hepatotoxicity. (C) This is incorrect because the capsulecan be emptied and mixed with fluids or food if needed. (D)Food may delay peak serum levels.
  10. 60. A client is diagnosed with Mycobacterium tuberculosis.He is placed in respiratory isolation, intubated, and receivesmechanical ventilation. When performing suctioning,the nurse should:A. Suction for a maximum of 20 secondsB. Hyperoxygenate before and after suctioningC. Suction for a maximum of 30 secondsD. Maintain clean technique during suctioning
    60. (B) Client need: physiological integrity; subcategory: physiologicaladaptation; content area: med/surgRATIONALE(A) The maximum time for suctioning is 10–15 seconds. (B) SupplementalO2 should be administered before and after suctioningto reduce hypoxia. (C) The maximum time for suctioning is10–15 seconds. (D) Strict sterile technique should be used duringsuctioning.
  11. 61. The physician prescribes a medical regimen of isoniazid,rifampin, and vitamin B6 for a tuberculosis client. Thenurse instructs the client that B6 is given because it:A. Increases activity of isoniazidB. Increases activity of rifampinC. Improves nutritional statusD. Reduces peripheral neuropathy
    61. (D) Client need: physiological integrity; subcategory: pharmacologicaland parenteral therapies; content area: med/surgRATIONALE(A) Vitamin B6 does not enhance the activity of isoniazid. (B)Vitamin B6 does not enhance the activity of rifampin. (C) A vitaminalone does not improve nutritional status. (D) Isoniazid leads to VitaminB6 deficiency, which is manifested as peripheral neuropathy.
  12. 62. Which of the following nursing actions is essential toprevent drug-resistant tuberculosis?A. Monitor liver function.B. Monitor renal function.C. Assess knowledge of respiratory isolation.D. Monitor compliance with drug therapy
    62. (D) Client need: health promotion and maintenance; subcategory:prevention and early detection of disease; content area:med/surgRATIONALE(A) Monitoring liver function will not prevent the developmentof drug-resistant organisms. (B) Monitoring renal function willnot prevent the development of drug-resistant organisms. (C)Knowledge of respiratory isolation will reduce transmission oftuberculosis but will not prevent development of drug-resistantorganisms. (D) Noncompliance with prescribed antituberculosisdrug regimen is the primary cause of drug-resistant organisms.Noncompliance permits the mutation of organisms
  13. 103. Someone who has received a recent tattoo should be screened for:1. tuberculosis.2. HIV.3. Hepatitis C.4. Syphilis.
    (3) Hepatitis B and C are associated with tattooing. It is possible, but not as probable that HIV could be transmitted viathe needle if sterile technique is not followed. Many tattoo parlors share ink wells with customers, and this is the sourceof transmission of blood-borne pathogens. Syphilis can also be transmitted by blood-borne routes but would be unlikelydue to the larger sized bacterium.
  14. 131. A client is seen in the emergency room following an indoor party and was diagnosed with Tuberculosis. Thenurse should explain to the client that this type of infection is transmitted in which of the following ways?1. vehicle2. vector3. airborne4. direct contact
    (3) Tuberculosis is an airborne organism and can be obtained by being exposed to the microorganisms through theair—especially in closed areas. This usually is manifested in the respiratory system; symptoms include vomiting blood,vague chest pain, night sweats, dypsnea. The bacillus is generally sensitive to isoniazid (INH), paraaminosalicylic acid,streptomycin, rifampin, others (combination of drugs is prescribed). Nursing intervention should include: medication,asceptic technique, nutrition, danger symptoms, multiple teaching.
  15. 134. A 30-year-old client is preparing for discharge from the hospital when the client develops a temperature of102.8°F. The nurse determines that the client is experiencing an infection termed:1. nosocomial.2. extracorporeal.3. incidental.4. resistant
    (1) Nosocomial infections are classified as infections that are associated with the delivery of healthcare services in ahealthcare facility. Nosocomial infections can either develop during a client’s stay in a facility or manifest after discharge.Nosocomial microorganisms (for example, tuberculosis and HIV) may also be acquired by health personnelworking in the facility and can cause significant illness and time lost from work. The hands of personnel are a commonvehicle for the spread of microorganisms. Insufficient hand washing is thus an important factor contributing to thespread of nosocomial microorganisms.
  16. 142. The nurse is taking care of a client with tuberculosis needs to wear:1. masks.2. sterile gloves.3. clean gowns.4. sterile gowns.
    (1) Tuberculosis is an airborne bacteria infection (mycobacterium tuberculosis). The droplets from the tuberculosis canbe transmitted by the client to healthcare workers; thus, masks are of great importance.
  17. 150. The emergency triage nurse will perform which action upon receiving the history that the client has a severecough, fever, night sweats, and body wasting?1. Place the client in the waiting room until an available cubicle is open.2. Seclude the client from other clients and visitors.3. Take no intervention because it may not be necessary until tests confirm a disease.4. Don gown, gloves and mask immediately.
    (2) The client is describing signs and symptoms of tuberculosis. The client is potentially infectious to others and shouldbe secluded. A “respirator mask” should be worn by caregivers, but it is not necessary for the nurse to gown and glove. Ifthe client is moved to other areas such as radiology, a mask should be worn by the client and a “respirator mask” by thoseworking in close contact of the client.
  18. 151. Which of the following clients will require airborne precautions?1. a client with fever, chills, vomiting, and diarrhea2. a client suspected of varicella (chicken pox)3. a client with abdominal pain and purpura4. a client diagnosed with AIDS
    (2) Chicken pox (Varicella) is an acute, infectious airborne illness that requires others in direct contact to wear a“respirator,” a special face mask.
  19. 165. Which of the following situations require the nurse to don gloves?1. taking a tympanic temperature on a post operative client2. giving a sub cutaneous injection to a client on Heparin3. assessing the heart rate of a patient with tuberculosis4. assisting a patient to the bedside commode
    (2) Standard precautions involving gloves are required when the possibility of coming in contact with body fluids existwhether blood is readily seen or not.
  20. 169. The spread of active or primary tuberculosis is primarily by what means?1. blood2. droplet3. airborne4. contact
    (3) Although the tubercle bacillus can be spread from bovine to human via infected cow’s milk, it is primarily spreadby “sharing air” of the infected person, human to human contact.
  21. 136. When a patient has tuberculosis, what is the proper type of transmission-based precaution in which to place thepatient?1. standard precautions2. contact precautions3. droplet precautions4. airborne precautions
    (4) The client with tuberculosis needs to be placed on airborne precautions, as TB is spread by small-particle airbornebacteria. The remaining options describe other types of precautions.
  22. 76. Which of the following microorganisms is easily transmitted from patient to patient on the hands of healthcareworkers?1. mycobacterium tuberculosis2. clostridium tetani3. staphylococcus aureus4. human immunodeficiency virus
    (3) Staphylococcus aureus microorganisms are ubiquitous and easily transmitted by healthcare workers who fail toconduct routine handwashing between patients; tuberculosis is almost always transmitted by the airborne rou
  23. 183. A diagnostic test for tuberculosis is:1. hemoglobin electrophoresis.2. chest radiography.3. cardiac catheterization.4. blood test.
    (2) Chest radiography is a prime diagnostic evaluation for tuberculosis. Others include a PPD skin test and gastricaspirations. TB is contracted from another person with the disease by inhalation of droplets from coughing, sneezing,or spitting; assessment of client’s history, past and present signs and symptoms.
  24. 126. Ms. Roberts, a 23-year-old single mother oftwo young children, comes sporadically to theinfectious disease clinic for follow-up treatmentof tuberculosis. The nurse knows that she is onantidepressive medication because last week atthe clinic she dropped her pills, and the nursehappened to pick them up. To ensure propertreatment and follow-up, all the followinginterventions would be appropriate except:1. arrange to have Ms. Roberts meet with thesocial worker to discuss insurance benefits.2. schedule Ms. Roberts’ appointments duringher lunch break from work.3. tell Ms. Roberts that you understand howhard it is to comply with treatment when sheis feeling blue.4. keep crayons and paper in the waiting roomso that her children can occupy themselveswhile they wait.
    126. (3) If Ms. Roberts does not volunteer information about her depression, it would be inappropriate to discuss itwith her and in fact would be an invasion of her privacy. Physiological Adaptation
  25. 103. The nurse provides care to a client newlydiagnosed with tuberculosis who is beginningantibiotics. Which of the following medicationregimens will the nurse anticipate for this client?1. A single drug (monotherapy) is common ifthe infection is mild.2. Because the mycobacterium grows slowly,duration of treatment will be 9–18 months.3. Medication will include the use of three antiviralagents such as AZT, Saquinivir,Ritonavir.4. Typically the medication regimen willinclude 3 or 4 drugs such as Isoniazid,Rifampin, Pyrazinamide, Ethambutol
    103. (4) Treatment of tuberculosis is multi-drug therapy typically isoniazid, rifampin, pyrazinamide and ethambutol.Treatment is long term usually over a period of six months if the client is not drug resistant, but up to 24 monthsif there is drug resistance. Safety and Infection Control
  26. 237. Which of the following statements by a client whohas just tested positive for tuberculosis reveals heis able to care for himself?1. “After treatment, I will not have a relapse.”2. “I can stop taking my medication in twoweeks.”3. “I will take my medication when I feel bad.”4. “I will take my medication as ordered.”
    237. (4) A client with tuberculosis needs to take his medication as ordered, not just when he feels bad, otherwiseresistance to the antibiotics may develop. Most tuberculosis treatment regimens are at least 2 months, and maylast up to a year. Even with treatment, a client may relapse, as tuberculosis can be reactivated. Reduction of RiskPotential