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.
2Ask the client to remove the mask for a sputum specimen before room placement.
3Place a surgical mask on the client and move the client to an airborne infection isolation room.✓ Correct answer
4Begin droplet precautions and keep the clinic door open.
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.
In-depth explanation
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 scenario
Clinical Practice Guide CDC TB infection control guidance emphasizes prompt detection of infectious TB, airborne precautions, and treatment for presumed or confirmed TB disease.
Caution Do not confuse droplet precautions with airborne precautions for pulmonary TB.
Key concepts
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.