A nurse is caring for a hospitalized patient with confirmed influenza A. Which nursing intervention should be implemented first to prevent transmission to other patients and healthcare workers?
1Place the patient in droplet precautions with a private room✓ 정답
2Administer oseltamivir (Tamiflu) as prescribed
3Encourage increased fluid intake to prevent dehydration
4Monitor vital signs every 4 hours for fever patterns
해설
Droplet precautions are the priority to prevent nosocomial transmission via respiratory droplets. Other interventions like antiviral administration, hydration, and monitoring are important but secondary to infection control.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing action for a patient with a confirmed airborne/droplet-transmitted infection. The core theme is Infection Control and Standard Precautions. The principle of Key Point!Safety First is paramount in nursing. Before addressing the patient's specific symptoms or treatment, the nurse's first responsibility is to protect other patients, visitors, and healthcare workers from acquiring the infection. Influenza A is primarily spread through respiratory droplets generated when an infected person coughs, sneezes, or talks.
Answer Rationale: The correct answer is ① Place the patient in droplet precautions with a private room. This is the immediate and priority intervention. According to the Centers for Disease Control and Prevention (CDC) guidelines, droplet precautions require a private room (or cohorting with another patient with the same infection) and the use of a surgical mask for healthcare personnel when within 3-6 feet of the patient. This action directly interrupts the chain of infection (mode of transmission) and is the foundation of safe care. All other care follows this essential safety step.
Distractor Analysis:
Watch out for confusion!② Administer oseltamivir (Tamiflu): While this is a correct and important intervention to treat the patient's infection, it is a treatment action, not the first safety and prevention action. The nurse must secure the environment first.
Watch out for confusion!③ Encourage increased fluid intake: This is supportive care for a patient with fever and potential dehydration, but it does nothing to prevent transmission to others. It addresses a patient problem, not a public health/safety problem.
Watch out for confusion!④ Monitor vital signs every 4 hours: This is part of ongoing assessment and monitoring. Again, it is important for the individual patient's care plan but is not the immediate priority to protect others from a communicable disease.
Related Concepts: This question integrates knowledge of transmission-based precautions (Contact, Droplet, Airborne), the nursing process (assessment and safety come before implementation of specific orders), and priority-setting frameworks (like ABCs and Maslow's Hierarchy—safety needs are a high priority).
Concept Summary
Concept
Key Takeaway
Chain of Infection
Interrupting transmission (via isolation) is a primary nursing responsibility.
Transmission-Based Precautions
Droplet: For pathogens spread by large droplets (e.g., Influenza, Pertussis, Meningitis). Requires private room/surgical mask.
Airborne Precautions
For smaller, airborne particles (e.g., Tuberculosis, Measles, Varicella). Requires negative pressure room and N95 respirator.
Nursing Priorities
Safety of all (patient, others, self) often takes precedence over individual treatment tasks.
Side-by-Side Comparison!
Precaution Type
Pathogen Examples
Key Requirements
PPE (Personal Protective Equipment)
Contact
MRSA, VRE, C. diff, RSV
Private room preferred; dedicated equipment
Gown & Gloves
Droplet
Influenza, Pertussis, Meningococcal meningitis
Private room; mask within 3-6 ft of patient
Surgical Mask
Airborne
TB (Tuberculosis), Measles, Varicella
Negative pressure room; door closed
N95 or higher respirator
Anatomy, Physiology & Pharmacology Points
• Influenza Virus: Attacks the respiratory epithelium. Transmission occurs via droplets (>5 microns) that land on mucosal surfaces (nose, mouth, eyes).
• Oseltamivir (Tamiflu): A neuraminidase inhibitor. It works by blocking the release of new viral particles from infected cells, shortening the duration of symptoms if started early (within 48 hours).
Memory Tips
• Droplet Diseases: Remember "SPIDERMAN" – Some people say it's "My BIG DROP": Meningitis, Influenza, Bordetella (pertussis), German measles (Rubella) – but a simpler one is: Think of things that make you cough/sneeze big droplets – Flu, Whooping cough, Mumps, Pneumonia (some bacterial).
• Priority Setting: Use "SAFETY FIRST". When an action protects others from harm (infection, injury), it is almost always the priority.
High-Frequency NCLEX Topics
Infection control is a Key Point!High Yield area. The NCLEX loves to test:
1. Identifying the correct type of precaution for a given disease.
2. Selecting the first or priority action in an infection scenario.
3. Proper sequence for donning (gown → mask → goggles → gloves) and doffing (gloves → goggles → gown → mask) PPE.
Watch Out for Question Variations!
• Instead of "what should be done first?", it could be: "The nurse enters the room of a patient on droplet precautions. Which personal protective equipment (PPE) is required?"
• Or: "A patient with suspected tuberculosis is admitted. Which room assignment is most appropriate?" (Answer: A negative pressure isolation room).
• The scenario could shift from influenza to meningitis or pertussis, but the principle of initiating droplet precautions remains the same.
Nursing Clinical Practice GuideClinical Scenario: You are the charge nurse on a medical-surgical unit. A 68-year-old patient is admitted with fever, cough, myalgia, and a positive rapid test for Influenza A. The unit is full, and the next bed is occupied by an elderly patient recovering from pneumonia.
Nursing Intervention Strategy:
1Immediate Action (Priority)Place the patient in a private room immediately. If no private room is available, consult infection control to cohort with another influenza patient. Place a "Droplet Precautions" sign on the door.
2Education & CommunicationInstruct the patient on respiratory hygiene: "Please cover your cough with a tissue or your elbow." Explain the purpose of isolation to reduce anxiety. Inform all staff entering the room of the precaution type.
3PPE UseEnsure a surgical mask is worn by anyone within 6 feet of the patient. Perform hand hygiene before and after patient contact and after removing PPE.
4Integrate Other CareAfter precautions are established, administer prescribed antivirals (oseltamivir), encourage fluids, provide antipyretics for fever, and monitor respiratory status.
Patient Safety and Precautions:
• Transport: Limit patient movement outside the room. If transport is essential, the patient must wear a surgical mask.
• Visitors: Instruct visitors on proper hand hygiene and mask use. Screen visitors for symptoms.
• Duration: Droplet precautions for influenza are typically maintained for 5-7 days after illness onset or until 24 hours after fever resolves without antipyretics.
Nursing Procedure & Medication FlowProcedure: Initiating Droplet Precautions
1. Assess need based on diagnosis/symptoms.
2. Obtain private room or cohort.
3. Place appropriate signage.
4. Stock room with PPE (masks, gowns if soiling is likely, gloves).
5. Educate patient and staff.
6. Document initiation of precautions in the chart.
Medication: Oseltamivir (Tamiflu) Administration
• Timing: Most effective if started within 48 hours of symptom onset.
• Dosing: Typically 75 mg orally twice daily for 5 days.
• Nursing Consideration: Can cause nausea/vomiting. Administer with food.
A Word from Your Senior Nurse
"In the real world, infection prevention is everyone's job. That 'Droplet Precautions' sign isn't just a piece of paper—it's a shield for the vulnerable patient in the next bed and for your own health. Always think: 'What can I do right now to stop this bug from spreading?' That mindset makes you a safe and effective nurse. On the NCLEX, they are testing if you have that safety-first instinct. Never get so focused on the tasks for one patient that you forget your responsibility to all the others."
Droplet Precautions — Infection control measures for diseases spread by large respiratory droplets (e.g., influenza, pertussis). Requires a private room and surgical mask for close contact.
Influenza A — A contagious respiratory illness caused by influenza A viruses. Symptoms include fever, cough, sore throat, myalgia, and fatigue. Spread via droplets.
Chain of Infection — The process by which an infection spreads: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host. Nursing interventions aim to break this chain.
Oseltamivir — An antiviral neuraminidase inhibitor used to treat and prevent influenza A and B infections. Most effective when started early in the illness.
Standard Precautions — The basic level of infection control that should be used in the care of all patients all the time. Includes hand hygiene and use of PPE based on anticipated exposure.