a client is admitted to isolation with the diagnosis of active tuberculosis which infection control measures should the nurse implement
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Nursing Elites

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HESI CAT Exam

1. When admitting a client diagnosed with active tuberculosis to isolation, which infection control measures should the nurse implement?

Correct answer: A

Rationale: The correct answer is A: Negative pressure environment. Tuberculosis is transmitted through airborne particles, so a negative pressure room is essential to prevent the spread of the bacteria. Choice B, contact precautions, are used for infections spread by direct or indirect contact, not for tuberculosis. Choice C, droplet precautions, are for infections transmitted through respiratory droplets, not airborne particles like tuberculosis. Choice D, protective environment, is used for protecting immunocompromised patients from outside pathogens, not for preventing the spread of tuberculosis.

2. The nurse is caring for a comatose client. Which assessment finding provides the greatest indication that the client has an open airway?

Correct answer: C

Rationale: The correct answer is C: "Bilateral breath sounds can be auscultated." This finding indicates that air is moving adequately in and out of both lungs, confirming an open airway. Options A, B, and D are incorrect. Asymmetrical chest expansion may indicate lung or chest wall abnormalities, percussion revealing dullness over the lung area may suggest consolidation or fluid, and turning the client q2h is a position change intervention to prevent complications, not a direct assessment of airway patency.

3. The healthcare provider is completing a head-to-toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the healthcare provider?

Correct answer: B

Rationale: Clear fluid leaking from the nose is concerning for cerebrospinal fluid leakage, which is a medical emergency requiring immediate intervention. Sluggish pupillary response to light may indicate neurological issues but is not as urgent as CSF leakage. Complaint of severe headache is important but not as critical as the possibility of CSF leakage. Periorbital ecchymosis of the right eye could be indicative of trauma but does not pose an immediate threat to the patient's life.

4. When educating a group of school-age children on reducing the risk of Lyme disease, which instruction should the camp nurse include?

Correct answer: C

Rationale: The correct instruction to reduce the risk of Lyme disease is to wear long sleeves and pants. This helps prevent tick bites, which are the primary mode of transmission for Lyme disease. Wearing protective clothing reduces the skin's exposure to ticks, decreasing the chances of getting bitten. Washing hands frequently (Choice A) is important for general hygiene but not specifically for preventing Lyme disease. Avoiding drinking lake water (Choice B) is unrelated to the prevention of Lyme disease. Not sharing personal products (Choice D) is important for preventing the spread of infections but does not directly reduce the risk of Lyme disease.

5. Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms?

Correct answer: C

Rationale: Eosinophils are the correct answer. Eosinophils are specialized white blood cells that play a crucial role in allergic responses and combating parasitic infections. They release substances to destroy parasites and modulate allergic reactions. Neutrophils (Choice A) are mainly involved in fighting bacterial infections. Lymphocytes (Choice B) play a key role in the immune response, including antibody production, but are not primarily responsible for combating parasites or allergic responses. Monocytes (Choice D) are involved in immune defense, differentiating into macrophages or dendritic cells, but they are not mainly associated with allergic responses or parasitic worm destruction.

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