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Difficulty: HardStandard and Transmission-Based Precautions

A rapid response team is called to the room of a client who was admitted with fever, night sweats, and a productive cough. The client has pending sputum cultures for Mycobacterium tuberculosis and has suddenly developed severe respiratory distress with active hemoptysis. Which of the following actions should the responding nurses take? Select all that apply.

  1. Don an N95 or higher-level respirator immediately upon entering the client's room.Answer
  2. B
    Prioritize applying oxygen via a high-flow device before donning personal protective equipment to address the acute hypoxia.
  3. Ensure the door to the client's room remains tightly closed throughout the emergency intervention.Answer
  4. Wear a fluid-resistant gown, clean gloves, and protective eyewear during the resuscitation efforts.Answer
  5. E
    Delegate the task of performing deep nasotracheal suctioning to an unlicensed assistive personnel to rapidly clear the airway.
  6. F
    Place a standard surgical mask over the client's mouth and nose during the respiratory interventions to contain aerosols.

Answer

The responding nurses should don an N95 respirator, ensure the room door remains closed, and wear a gown, gloves, and protective eyewear during the resuscitation efforts.
The correct actions prioritize the safety of the healthcare team through the use of Airborne Precautions (N95 respirator and a closed door) while simultaneously applying Standard Precautions (gown, gloves, eyewear) for an emergency procedure with a high risk of blood and body fluid exposure. These combined actions allow for the safe and effective resuscitation of the client without risking secondary transmission.

Step-by-Step Solution

1
Analyze the client's symptoms (fever, night sweats, productive cough) and pending diagnostic tests.
The client is highly suspected of having active pulmonary tuberculosis, which requires Airborne Precautions.
Airborne Precautions mandate the use of an N95 respirator and a closed door in a negative pressure room to prevent the transmission of small droplet nuclei.
2
Evaluate the impact of the acute complication (severe respiratory distress and hemoptysis) on standard infection control protocols.
The situation involves a high risk of blood and body fluid splash and requires immediate, hands-on airway interventions.
Standard Precautions require the addition of a fluid-resistant gown, clean gloves, and protective eyewear during any procedure with a high risk of splashing.
3
Determine the correct prioritization and delegation of actions for the healthcare team responding to the emergency.
Nurses must don appropriate PPE before intervening, cannot delegate complex airway management to a UAP, and must not obstruct the client's airway with a surgical mask.
Prioritizing self-protection prevents staff exposure, and airway interventions on unstable clients require advanced registered nurse skills.

Key Concept

Integrating Airborne Precautions with emergency resuscitation priorities and delegation principles.
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Topics

Standard and Transmission-Based Precautions

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