A nurse is working in a busy emergency department when a patient with suspected tuberculosis arrives. What is the most appropriate action for the nurse to take first to ensure workplace safety?
A 45-year-old homeless man presents to the emergency department with a 3-week history of persistent cough, night sweats, weight loss, and hemoptysis. He appears malnourished and reports living in a crowded shelter.
1Obtain a detailed health history from the patient
2Start an IV line and collect blood samples for laboratory tests
3Place the patient in airborne isolation precautions immediately✓ 정답
4Administer oxygen therapy via nasal cannula
해설
When tuberculosis is suspected, immediate airborne isolation is critical to prevent transmission. Other actions like history-taking or starting an IV are secondary to infection control.
Core Nursing ExplanationKey Concept Analysis: This question tests the application of Standard and Transmission-Based Precautions in a clinical setting, specifically for a patient with suspected Tuberculosis (TB). The core principle is the Key Point!nurse's responsibility to protect themselves, other healthcare workers, and other patients from infection. Tuberculosis is transmitted via airborne droplets (droplet nuclei) that can remain suspended in the air for long periods, making immediate isolation the highest priority action before any other detailed assessment or intervention.
Answer Rationale: The correct answer is to Place the patient in airborne isolation precautions immediately. The patient's symptoms (persistent cough, night sweats, weight loss, hemoptysis) and social history (homeless, living in a crowded shelter) are classic for suspected pulmonary TB. According to the CDC (Centers for Disease Control and Prevention) and hospital infection control protocols, Key Point! any patient with signs/symptoms suggesting an airborne disease like TB must be placed in Airborne Infection Isolation (AII), also known as a negative pressure room, and staff must don a N95 respirator or higher-level PPE (Personal Protective Equipment) before prolonged close contact. This action takes precedence because it stops the chain of transmission at the portal of exit.
Distractor Analysis:
Watch out for confusion! Option ① (Obtain a detailed health history) is an important part of the nursing process, but performing this at the bedside without first implementing isolation would expose the nurse and others to the pathogen. The history can be obtained after isolation is initiated, often through the door or with appropriate PPE.
Option ② (Start an IV line and collect blood samples) is a secondary intervention. While labs are needed, this procedure involves close contact and could generate aerosols (if the patient coughs), increasing transmission risk without proper isolation in place.
Option ④ (Administer oxygen therapy) might seem urgent due to symptoms like cough and hemoptysis, but administering oxygen via nasal cannula does not contain infectious droplets and could potentially aerosolize secretions further. More critically, patient safety is secondary to public health safety in this context; preventing an outbreak is the immediate priority.
Related Concepts: This scenario highlights the "Safety First" principle, which often aligns with the ABC (Airway, Breathing, Circulation) priority framework but is superseded by Key Point!infection control and hazard prevention when a communicable disease threat is present. The order of actions follows: 1) Contain the hazard, 2) Protect yourself and others, 3) Then assess and treat the patient.
Negative pressure room, Keep door closed, Limit transport
N95 respirator or PAPR
Droplet
Influenza, Pertussis, Meningitis
Private room or cohort, Mask on patient during transport
Surgical mask
Contact
MRSA, VRE, C. difficile, RSV
Private room, Dedicated equipment, Emphasis on hand hygiene
Gown & Gloves
Anatomy, Physiology & Pharmacology Points
• Pathophysiology: Mycobacterium tuberculosis primarily affects the lungs. The bacteria are inhaled, multiply, and cause a granulomatous inflammatory response. Cavities form in the lung tissue, which can erode into blood vessels, causing hemoptysis.
• Diagnosis: Sputum for AFB (Acid-Fast Bacilli) smear and culture, Chest X-ray (showing infiltrates/cavities), Tuberculin skin test (TST) or IGRA (Interferon-Gamma Release Assay).
• Treatment: Multi-drug regimen (RIPE): Rifampin, Isoniazid, Pyrazinamide, Ethambutol. Directly Observed Therapy (DOT) is standard to ensure adherence.
Memory Tips
• Airborne Diseases: Remember "My Chicken Has TV" - Measles, Chickenpox (Varicella), Herpes Zoster (disseminated), Tuberculosis.
• Priority Acronym: Think "Stop the Spread, Save the Staff" (Safety/Isolation first).
High-Frequency NCLEX Topics
NCLEX heavily tests infection control and safety. You must know the differences between precaution types, required PPE, and the Key Point!sequence of actions when a potential hazard is identified. Questions often present a patient with specific symptoms and ask for the "first," "priority," or "most appropriate" action.
Watch Out for Question Variations!
• Variation 1: "The nurse is preparing to enter the room of a patient on Airborne Precautions for TB. Which action by the nurse is correct?" (Answer: Donning a fit-tested N95 respirator).
• Variation 2: "Which patient should be placed in a negative pressure room?" (Answer: The patient with a new cough, night sweats, and an abnormal chest X-ray).
• Variation 3: "A patient with active TB is being transported for a CT scan. What should the nurse ensure?" (Answer: The patient wears a surgical mask during transport).
Nursing Clinical Practice GuideClinical Scenario: You are triaging in the ED. A 45-year-old man walks in, coughing persistently into his sleeve. He looks thin and tired. When you ask the reason for his visit, he says, "I can't stop coughing, and I'm coughing up a little blood. I've been sweating all night and have no appetite." He mentions living in a homeless shelter. Your "spidey-sense" for infection control should immediately tingle.
Nursing Intervention Strategy:
1Immediate Action (First 30 seconds)Do NOT bring the patient into the common waiting area. If he's already there, provide him with a surgical mask and instruct him to keep it on. Immediately notify the charge nurse/physician of a "Rule-out TB" case and coordinate to place the patient directly into an Airborne Infection Isolation (AII) room.
2Assessment with PPEAfter the patient is isolated, don your N95 respirator (perform a user seal check!), and then enter to obtain a more detailed history and initial assessment.
3Specimen CollectionCollect sputum samples for AFB testing (usually 3 consecutive morning samples). Educate the patient on producing a deep cough specimen.
4Collaborative CareNotify the infection control team. Administer medications as ordered (often after diagnosis). Plan for Directly Observed Therapy (DOT) if the patient is diagnosed and discharged.
Patient Safety and Precautions:
• Key Point!Negative Pressure Room: Verify the room is functioning correctly (air flowing into the room, not out). Keep the door closed at all times.
• PPE: N95 must be fit-tested annually. A PAPR (Powered Air-Purifying Respirator) is used if an N95 is not available or for staff with facial hair that prevents a seal.
• Visitor Instructions: Limit visitors. Those who must visit should be screened for immunity/risk and instructed on PPE use.
Nursing Procedure & Medication FlowProcedure: Placing a Patient in Airborne Isolation
1. Identify need based on signs/symptoms or diagnosis.
2. Alert registration/ED team to divert patient to AII room.
3. Place appropriate signage on the door.
4. Ensure patient wears a surgical mask if outside the room.
5. Gather all necessary equipment (meds, linens) before entering to minimize exits/entries.
6. Don N95 respirator and other PPE as needed (gown/gloves if contact is anticipated).
7. Provide care.
8. Remove PPE carefully upon exit (gloves/gown first, then perform hand hygiene, then remove N95 by the straps, then hand hygiene again).Medication: First-Line TB Drugs
• Isoniazid (INH): Monitor for Watch out for confusion! peripheral neuropathy (give with Pyridoxine/Vitamin B6) and hepatotoxicity (monitor LFTs).
• Rifampin: Turns body fluids (urine, sweat, tears) orange/red. Is a major CYP450 enzyme inducer (reduces effectiveness of many other drugs like oral contraceptives, warfarin).
• Patient education on adherence is critical to prevent MDR-TB (Multi-Drug Resistant TB).
A Word from Your Senior Nurse
"In the real world of the ED, things move fast, and a coughing patient is common. But linking those classic TB symptoms—especially in a high-risk population—is what makes you a vigilant nurse. Never feel awkward or rude for masking a patient or rushing them to isolation. You're not just protecting yourself; you're protecting the pregnant woman in the next bed, the elderly patient with COPD, and the immunocompromised oncology patient down the hall. That first action of isolation is the most powerful infection control intervention you have. On the NCLEX, they are testing your ability to recognize that public health responsibility instantly. Think: 'Contain first, ask questions later.'"
Airborne Precautions — Infection control measures for diseases transmitted by airborne droplet nuclei (e.g., TB, measles). Requires a negative pressure room and N95 respirator.
Mycobacterium tuberculosis — The bacterium that causes tuberculosis (TB). It is an acid-fast bacillus (AFB) that primarily affects the lungs.
N95 Respirator — A personal protective device designed to achieve a very close facial fit and efficient filtration of airborne particles (95% efficiency). Must be fit-tested.
Hemoptysis — Coughing up blood or blood-stained sputum from the respiratory tract. A classic symptom of conditions like tuberculosis and lung cancer.
Negative Pressure Room — A ventilation system where air flows into the room from the corridor and is exhausted directly outside, preventing contaminated air from escaping into other areas. Essential for airborne isolation.