A nurse is working in a busy emergency department when a 45-year-old patient with suspected tuberculosis arrives. The patient presents with persistent cough, night sweats, and unintentional weight loss over the past 3 months, reports recent travel to a country with high tuberculosis prevalence, and has a chest X-ray showing suspicious pulmonary infiltrates. What is the most important safety measure the nurse should implement first?
A 45-year-old patient presents to the emergency department with a persistent cough, night sweats, and unintentional weight loss over the past 3 months. The patient reports recent travel to a country with high tuberculosis prevalence. Chest X-ray shows suspicious pulmonary infiltrates, and the physician orders sputum collection for acid-fast bacilli testing.
1Place the patient in a standard isolation room with contact precautions
2Immediately place the patient in an airborne isolation room with negative pressure ventilation✓ 정답
3Provide the patient with a standard surgical mask and maintain droplet precautions
4Keep the patient in the general waiting area until test results are confirmed
해설
Tuberculosis requires immediate airborne isolation with negative pressure ventilation to prevent transmission through airborne droplets. Other options are inadequate for protecting healthcare workers and other patients.
Core Nursing ExplanationKey Concept Analysis: This question tests the immediate nursing action for a patient with suspected Tuberculosis (TB). TB is an infectious disease caused by Mycobacterium tuberculosis and is transmitted via airborne droplet nuclei. When a patient with active pulmonary TB coughs, sneezes, or speaks, they expel these tiny particles that can remain suspended in the air for hours and be inhaled by others. The clinical presentation (chronic cough, night sweats, weight loss, travel history, and abnormal chest X-ray) strongly suggests active pulmonary TB, which is highly contagious.
Answer Rationale: Key Point! The single most important and immediate nursing action for a patient with suspected active pulmonary TB is to implement Airborne Precautions. This requires placing the patient in a negative pressure isolation room (also called an airborne infection isolation room - AIIR). The negative pressure ensures that air flows into the room from the corridor, preventing contaminated air from escaping into other areas. Anyone entering the room must wear a fit-tested N95 respirator (or higher-level protection). This action is taken based on suspicion, not confirmation, to immediately protect public health.
Distractor Analysis:
Watch out for confusion! Option ① (standard isolation with contact precautions) is incorrect because Contact Precautions are for diseases spread by direct contact or contact with contaminated surfaces (e.g., MRSA, C. diff). TB is not primarily spread by contact.
Option ③ (surgical mask and droplet precautions) is a critical error. A standard surgical mask protects others from the wearer's large droplets but does not protect the healthcare worker from inhaling the small airborne particles of TB. Droplet Precautions (for diseases like influenza, pertussis) are for larger droplets that travel only about 3-6 feet. TB requires the higher level of Airborne Precautions.
Option ④ (keeping in general waiting area) is dangerously incorrect. This would expose numerous other patients, visitors, and staff to a potentially highly contagious disease, violating fundamental infection control principles and public health safety.
Related Concepts: The decision to isolate is based on clinical and epidemiological suspicion. Diagnostic confirmation (sputum for acid-fast bacilli smear/culture) takes time. The nurse's role is to initiate precautions immediately upon suspicion. Other key components of TB management include ensuring the patient wears a surgical mask during transport, coordinating prompt diagnostic testing, and initiating antitubercular medication therapy as ordered.
Nursing Clinical Practice GuideClinical Scenario: You are triaging a patient in the ED who reports a 3-month history of worsening cough, drenching night sweats, and a 10-pound weight loss. They recently returned from a visit to family in a country with high TB burden. They are currently coughing frequently.
Nursing Intervention Strategy:
1Immediate ActionAlert the charge nurse and physician of the need for airborne isolation. Do not let the patient remain in the open triage or waiting area. If a negative pressure room is not immediately available, place the patient in a private room with the door closed and place a surgical mask on the patient. Post "Airborne Precautions" signs.
2TransportIf the patient must be moved for tests (e.g., CT scan), the patient should wear a surgical mask during transport to contain their respiratory secretions. Notify the receiving department in advance.
3PPE for StaffAnyone entering the isolation room must wear a properly fitted N95 respirator. Perform a user seal check each time.
4Diagnostic CoordinationCollect sputum specimens as ordered (often 3 early morning specimens) for AFB smear and culture. Ensure specimens are collected in a safe manner, preferably in the isolation room or with the patient wearing a mask.
5Patient EducationEducate the patient on the importance of covering their mouth/nose when coughing, using tissues, and adhering to respiratory hygiene. Explain the purpose of isolation to gain cooperation.
Patient Safety and Precautions:
1ContraindicationsNever place an immunocompromised patient (e.g., chemotherapy patient) near a suspected TB case.
2MonitoringMonitor for respiratory distress and effectiveness of cough. Monitor for side effects once antitubercular drugs (like isoniazid, rifampin, pyrazinamide, ethambutol) are started.
3Public Health ReportingTB is a reportable disease. The infection control team and public health department will need to be notified to initiate contact tracing.
Nursing Procedure & Medication FlowAirborne Precautions Setup:
1. Identify need based on signs/symptoms and history.
2. Place patient in AIIR (negative pressure room). Verify negative pressure with smoke test or indicator.
3. Post clear signage on door: "Airborne Precautions."
4. Keep door closed at all times.
5. Limit patient transport. If essential, patient wears surgical mask.
6. Use dedicated patient-care equipment if possible.Medication Note: First-line TB drugs (e.g., Isoniazid) can cause hepatotoxicity. Monitor liver function tests. Ethambutol can cause optic neuritis (monitor for red-green color discrimination and visual acuity). Pyridoxine (Vitamin B6) is often given with Isoniazid to prevent peripheral neuropathy.
A Word from Your Senior Nurse
"In the ED, speed and accuracy in initiating isolation can prevent an outbreak. Remember your hierarchy of controls: first, engineer the hazard away (negative pressure room), then administer controls (respirators). Don't wait for lab confirmation—if it walks like TB and talks like TB (with a cough), isolate it as TB. Your quick thinking protects your colleagues, other vulnerable patients, and the community. On the NCLEX, 'first' and 'priority' actions in infection control are always about safety first!"
Airborne Precautions — Infection prevention measures for diseases transmitted via airborne droplet nuclei (e.g., TB, measles, varicella). Requires a negative pressure isolation room and use of an N95 respirator or higher.
Negative Pressure Isolation Room — A ventilation system where air pressure inside the room is lower than in the surrounding areas, causing air to flow into the room when the door is opened, preventing contaminated air from escaping.
Mycobacterium tuberculosis — The acid-fast bacillus that causes tuberculosis. It is a slow-growing bacterium that primarily affects the lungs but can disseminate to other organs (extrapulmonary TB).
N95 Respirator — A personal protective equipment device designed to achieve a very close facial fit and efficient filtration of airborne particles (95% of test particles). Must be fit-tested for each wearer.
Acid-Fast Bacilli (AFB) Smear/Test — A laboratory test performed on sputum or other specimens to detect the presence of mycobacteria, which retain dye after an acid wash. A positive smear suggests active TB but requires culture for definitive diagnosis.