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Difficulty: MediumStandard and Transmission-Based Precautions

A triage nurse in a community health clinic evaluates a pediatric client presenting with a high fever, cough, coryza, and a widespread maculopapular rash that started on the forehead and is spreading downward. The accompanying caregiver states the child has not received any routine immunizations. Which immediate infection control and safety actions should the nurse implement? Select all that apply.

  1. Escort the client and caregiver directly into a negative-pressure airborne infection isolation room (AIIR).Answer
  2. B
    Initiate droplet precautions by placing the client in a standard private examination room with the door closed.
  3. Don a fit-tested N95 respirator or powered air-purifying respirator (PAPR) before entering the client's room.Answer
  4. D
    Place a fit-tested N95 respirator on the client while they are in the waiting area or during any necessary transport.
  5. Ensure the door to the isolation room remains completely closed except during essential entry and exit.Answer
  6. F
    Delegate the initial vital signs and skin assessment to the unlicensed assistive personnel (UAP) to expedite isolation procedures.

Answer

The nurse should escort the client into an AIIR, don an N95 or PAPR, and ensure the isolation room door remains closed.
The client's symptoms and vaccination status are a classic presentation of rubeola (measles), a highly contagious viral illness that requires airborne precautions. Appropriate airborne precautions dictate that the client must be immediately isolated in a negative-pressure room (AIIR) to safely vent the air. Furthermore, the door must remain closed to maintain negative pressure, and any healthcare personnel entering the room must wear a fit-tested N95 respirator or PAPR to prevent inhalation of aerosolized viral particles.

Step-by-Step Solution

1
Analyze the clinical presentation and history.
The combination of fever, cough, coryza, descending maculopapular rash, and lack of immunizations strongly indicates rubeola (measles).
Accurate pathogen identification dictates the necessary level of transmission-based precautions.
2
Determine the correct isolation category.
Measles requires airborne precautions.
The rubeola virus remains suspended in the air over long distances and extended time periods.
3
Select the appropriate facility and PPE interventions for airborne precautions.
The client needs an AIIR, the door must be kept closed, and staff must wear N95 respirators or PAPRs.
These specific interventions are standard CDC protocols for managing airborne pathogens.
4
Evaluate delegation and patient transport protocols.
Initial assessment cannot be delegated, and clients should wear a standard surgical mask, not an N95, during transport.
Ensuring safe delegation and appropriate patient source control prevents further safety hazards.

Key Concept

Airborne Precautions for Rubeola (Measles)
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Topics

Standard and Transmission-Based Precautions

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