HESI: HIV and Tuberculosis and Rationale
1.
The nurse admits client to a private room at the end of the hall. According to hospital protocol,
the nurse puts on a mask before starting the admission process. Client tells the nurse that their
significant other is downstairs and that they would like for them to stay in the room with them.
How should the nurse respond?
"They may stay, but they need to wear a mask."
(Client's significant other may stay in the room, but they should wear a mask to help decrease
the possibility of contracting the TB organism.)
2.
Client's significant other arrives. Client wants to know why a mask is necessary for people
entering their room. What teaching should the nurse implement?
Explain that the tuberculosis (TB) organism is most often spread through the air.
(When an infected person coughs or sneezes, they produce infectious droplets that can be
breathed in by another person. This answer provides client with the scientific rationale for
wearing a mask.)
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3.
The unlicensed assistive personnel (UAP) asks why client could not be in an empty semi-private
room closer to the nurse's station so the staff would not have to walk so far to provide care.
What information should the nurse provide to the UAP on infection control practices?
, The implementation of airborne precautions for possible TB requires a private, negative
pressure room assignment.
(According to the Centers for Disease Control (CDC), in addition to isolating client by using a
private room, engineering controls can help to prevent the spread of TB. Controlling the
direction of the airflow can prevent contamination of air in adjacent areas.)
4.
The nurse notices the UAP about to enter client's room to deliver a meal tray without wearing
any protective apparel. What information should the nurse provide to the UAP?
A fit-tested HEPA mask is required for healthcare workers entering the room of someone
suspected of having active TB.
(TB is spread by airborne transmission of droplet nuclei. A specific fit tested, high-efficiency
particulate air (HEPA) mask is necessary to filter the mycobacterium tuberculosis bacillus.)
5.
An acid-fast bacilli (AFB) stain is part of the initial admission orders. Early morning sputum
specimens will be collected for 3 consecutive days and sent to the lab.
Which tasks may the nurse delegate to the UAP? (Select all that apply. One, some, or all
options may be correct.)
-Have the UAP tell client that the specimen must be collected in the early morning.
-Provide client with three sterile specimen cups at his bedside.
-Document the time and date that each sputum specimen was collected.
(This task may be safely delegated. However, it is the nurse's responsibility to ensure that the
documentation is completed and sent with the specimen to the lab.)
6.
Client is scheduled for several activities the following morning. Which activity should client
perform first upon awakening?
Obtain the first of three sputum specimens for laboratory testing.
(Secretions collecting during the night provide the opportunity for the client to cough and
expectorate upon awakening before performing other morning activities.)
7.
The assigned practical nurse (PN) says to the RN charge nurse who is making assignments,
that they do not want to be assigned to care for this client because they have never cared for a
1.
The nurse admits client to a private room at the end of the hall. According to hospital protocol,
the nurse puts on a mask before starting the admission process. Client tells the nurse that their
significant other is downstairs and that they would like for them to stay in the room with them.
How should the nurse respond?
"They may stay, but they need to wear a mask."
(Client's significant other may stay in the room, but they should wear a mask to help decrease
the possibility of contracting the TB organism.)
2.
Client's significant other arrives. Client wants to know why a mask is necessary for people
entering their room. What teaching should the nurse implement?
Explain that the tuberculosis (TB) organism is most often spread through the air.
(When an infected person coughs or sneezes, they produce infectious droplets that can be
breathed in by another person. This answer provides client with the scientific rationale for
wearing a mask.)
Previous
Play
Next
Rewind 10 seconds
Move forward 10 seconds
Unmute
0:02
/
0:15
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Brainpower
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3.
The unlicensed assistive personnel (UAP) asks why client could not be in an empty semi-private
room closer to the nurse's station so the staff would not have to walk so far to provide care.
What information should the nurse provide to the UAP on infection control practices?
, The implementation of airborne precautions for possible TB requires a private, negative
pressure room assignment.
(According to the Centers for Disease Control (CDC), in addition to isolating client by using a
private room, engineering controls can help to prevent the spread of TB. Controlling the
direction of the airflow can prevent contamination of air in adjacent areas.)
4.
The nurse notices the UAP about to enter client's room to deliver a meal tray without wearing
any protective apparel. What information should the nurse provide to the UAP?
A fit-tested HEPA mask is required for healthcare workers entering the room of someone
suspected of having active TB.
(TB is spread by airborne transmission of droplet nuclei. A specific fit tested, high-efficiency
particulate air (HEPA) mask is necessary to filter the mycobacterium tuberculosis bacillus.)
5.
An acid-fast bacilli (AFB) stain is part of the initial admission orders. Early morning sputum
specimens will be collected for 3 consecutive days and sent to the lab.
Which tasks may the nurse delegate to the UAP? (Select all that apply. One, some, or all
options may be correct.)
-Have the UAP tell client that the specimen must be collected in the early morning.
-Provide client with three sterile specimen cups at his bedside.
-Document the time and date that each sputum specimen was collected.
(This task may be safely delegated. However, it is the nurse's responsibility to ensure that the
documentation is completed and sent with the specimen to the lab.)
6.
Client is scheduled for several activities the following morning. Which activity should client
perform first upon awakening?
Obtain the first of three sputum specimens for laboratory testing.
(Secretions collecting during the night provide the opportunity for the client to cough and
expectorate upon awakening before performing other morning activities.)
7.
The assigned practical nurse (PN) says to the RN charge nurse who is making assignments,
that they do not want to be assigned to care for this client because they have never cared for a
