An adult client in an urgent care clinic has a 3-week cough, night sweats, weight loss, and blood-tinged sputum. Which action should the nurse take first?
1Place the client in a private room with contact precautions and implement strict hand hygiene protocols.
2Place a surgical mask on the client and move the client to an airborne infection isolation room.✓ Correct answer
3Initiate droplet precautions and instruct the client to wear a mask while keeping the clinic door open.
4Ask the client to briefly remove the mask to provide a sputum specimen before applying airborne precautions.
Explanation
The symptoms suggest possible infectious pulmonary tuberculosis. The priority is source control and airborne isolation: mask the client and move the client to an airborne infection isolation room when available. Contact or droplet precautions alone do not control airborne droplet nuclei.
Clinical Judgment Recognize likely airborne disease, protect others first, and place the client in the correct isolation environment.
Memory Tip TB: mask the source, isolate the air, respirator for staff.
KR vs US NCLEX uses Transmission-Based Precautions terminology and expects rapid source control for suspected TB.
Clinical Practice GuideCDC TB infection control guidance emphasizes prompt detection of infectious TB, airborne precautions, and treatment for presumed or confirmed TB disease.
CautionDo not confuse droplet precautions with airborne precautions for pulmonary TB.
Tuberculosis — An airborne infection caused by Mycobacterium tuberculosis, often presenting with prolonged cough, fever, night sweats, weight loss, or hemoptysis.
Airborne Precautions — Transmission precautions using airborne isolation and respiratory protection for pathogens that remain suspended in air.
N95 Respirator — A fitted respirator used by health care personnel for protection from airborne particles such as TB droplet nuclei.