Difficulty: Medium
Average Score: 73%
Simulated
The nurse is assessing a newly admitted client whose chief complaint is 'coughing up blood' and whose recent history includes a productive cough and night sweats. What is the nurse's priority intervention?
Correct answer
B
Rationale
The correct answer is B: Initiate airborne precautions. This is the priority intervention because the client's symptoms of coughing up blood, productive cough, and night sweats are indicative of possible tuberculosis (TB), which is transmitted via airborne droplets. By initiating airborne precautions, the nurse can help prevent the spread of TB to other individuals.
Choice A (Initiate droplet precautions) is incorrect as TB is transmitted via airborne route, not droplets. Choice C (Place the client in a positive pressure room) is incorrect because positive pressure rooms are typically used for immunocompromised clients, not specifically for TB. Choice D (Initiate neutropenic precautions) is incorrect as neutropenic precautions are for clients with low immune function, not specifically for TB.
Choice A (Initiate droplet precautions) is incorrect as TB is transmitted via airborne route, not droplets. Choice C (Place the client in a positive pressure room) is incorrect because positive pressure rooms are typically used for immunocompromised clients, not specifically for TB. Choice D (Initiate neutropenic precautions) is incorrect as neutropenic precautions are for clients with low immune function, not specifically for TB.