During a routine morning assessment, a practical nurse notes that a client recently admitted to a semi-private room is exhibiting hemoptysis, night sweats, and a persistent productive cough. Suspecting potential active pulmonary tuberculosis, the nurse must initiate immediate precautions. Arrange the following nursing actions in the correct prioritized sequence to minimize the risk of pathogen transmission.
- 1Place a standard surgical mask over the client's nose and mouth.
- 2Instruct the client's roommate to leave the room and wait in a safe area.
- 3Exit the room temporarily to perform hand hygiene and don a fit-tested N95 respirator.
- 4Coordinate with the nursing supervisor to transfer the client to an airborne infection isolation room (AIIR).
- 5Document the client's respiratory findings and the initiation of isolation measures in the health record.
Answer
The correct sequence prioritizes source control first by masking the client, followed by protecting the immediate bystander (roommate), protecting the nurse (donning the N95), ensuring definitive environmental isolation (AIIR transfer), and finally documenting the event.
Infection control prioritization dictates that when a healthcare worker is already at the bedside and discovers an airborne risk, source control (masking the client) is the fastest and most effective first step. This is followed by removing bystanders, protecting oneself with appropriate PPE, establishing long-term environmental controls (AIIR), and concluding with documentation.
Step-by-Step Solution
Key Concept
Prioritization of Airborne Precautions and Immediate Infection Control