# A nurse is working in a community health clinic when a 45-year-old homeless man with a 3-week history of persistent cough, night sweats, weight loss, and hemoptysis arrives. He appears malnourished and reports living in a crowded shelter. What is the most appropriate action for the nurse to take first to ensure workplace safety?

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## 문제

A nurse is working in a community health clinic when a 45-year-old homeless man with a 3-week history of persistent cough, night sweats, weight loss, and hemoptysis arrives. He appears malnourished and reports living in a crowded shelter. What is the most appropriate action for the nurse to take first to ensure workplace safety?

## 보기

1. Obtain a detailed health history from the patient
2. Start an IV line and collect blood samples for laboratory tests
3. Place the patient in airborne isolation precautions immediately **✔ 정답**
4. Administer oxygen therapy via nasal cannula

**정답: 3**

## 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.

## 심화 해설

Clinical Context and Immediate Safety Priority

This patient presents with a classic tetrad of symptoms — persistent cough lasting 3 weeks, night sweats, weight loss, and hemoptysis — in the context of homelessness and shelter-based crowding. This constellation is highly suggestive of active pulmonary tuberculosis (TB). In the community clinic setting, the nurse’s first responsibility is to protect other patients, staff, and visitors from potential exposure to an airborne pathogen. Airborne infection isolation is the cornerstone of TB infection control because Mycobacterium tuberculosis is transmitted via droplet nuclei that remain suspended in air for prolonged periods [2].

Why Airborne Precautions Must Come First

Placing the patient in airborne isolation precautions immediately is the most appropriate initial action for workplace safety. The hierarchy of controls for occupational infectious hazards identifies source control and environmental containment as the highest-priority interventions [2]. Delaying isolation to obtain a health history, start an IV, or apply oxygen exposes the clinical environment to ongoing contamination. Even brief face-to-face interactions without appropriate respiratory protection can result in transmission, particularly in immunocompromised healthcare workers [1]. The case from France demonstrates that despite airborne precautions, transmission occurred in a high-risk unit to a healthcare worker on tumor necrosis factor α inhibitor therapy, underscoring that the risk begins the moment an infectious patient enters a shared airspace [1].

Rationale for Not Selecting the Other Options

- Obtaining a detailed health history (Option 1) is an essential step in the diagnostic workup but does not address the immediate environmental hazard. History-taking can be performed after the patient is placed in a negative-pressure room with the nurse wearing a fitted N95 respirator.

- Starting an IV and collecting blood samples (Option 2) is a secondary intervention that supports medical diagnosis and management but provides no protection against airborne transmission during the procedure.

- Administering oxygen therapy (Option 4) addresses potential hypoxemia from pulmonary involvement but, when delivered via nasal cannula, does not contain infectious aerosols. Standard nasal cannula flow can even disperse droplet nuclei further into the environment. Oxygenation needs can be assessed and managed after isolation is established.

Connecting Isolation Protocols to Diagnostic Pathways

Once airborne precautions are initiated, the duration of isolation is guided by diagnostic testing. A systematic review and meta-analysis examined the use of GeneXpert MTB/RIF compared to acid-fast bacilli (AFB) smear microscopy for de-isolation decisions in patients with suspected pulmonary TB . GeneXpert offers higher diagnostic accuracy and faster turnaround, which can reduce unnecessary isolation days while maintaining safety. This evidence reinforces that the initial isolation decision must be immediate and empiric, with subsequent de-isolation guided by rapid molecular testing results .

Occupational Risk and Vulnerable Healthcare Workers

The occupational transmission case highlights a critical staffing consideration: immunocompromised healthcare workers, such as those receiving biologic immunosuppressants, should not be assigned to frontline TB care in high-risk settings [1]. This principle extends to community clinics serving populations with high TB prevalence, including shelters. The nurse caring for this patient must verify their own immune status and ensure appropriate fit-testing for respiratory protection. The transmission pathways reviewed by Gehanno et al. emphasize that airborne particles represent a major biological hazard requiring engineering controls (negative-pressure rooms), administrative controls (triage protocols), and personal protective equipment (N95 respirators) in combination [2].References (research sources)

- [1]Occupational Transmission of Extensively Drug-Resistant Tuberculosis, France.Research articlePoignon C, Vandenbos F, Risso K, Viard D, Gydé E, Gaudart A, Chirio D, Veziris N, Carles M. (2026) · DOI: 10.3201/eid3203.251099

- [2]Infectious contamination of healthcare workers.Research articleGehanno JF, Rollin L, Bensefa-Colas L. (2026) · DOI: 10.1016/j.lpm.2026.104349

## 임상 시나리오

Clinical Safety Guide: Suspected Pulmonary Tuberculosis in the Community Setting

When a patient presents with a cough lasting 3 weeks or longer, night sweats, weight loss, and hemoptysis, especially with risk factors like homelessness or shelter exposure, active pulmonary tuberculosis must be presumed until ruled out. The immediate nursing priority is to protect the clinic environment by initiating airborne infection isolation. This means placing a standard surgical mask on the patient and escorting them directly to a designated negative-pressure isolation room, if available, or a private room with the door closed. No other clinical activity, including history-taking, vital signs, or specimen collection, should occur before this step.

Once the patient is isolated, the nurse should don a fit-tested N95 respirator or powered air-purifying respirator before re-entering the room. All subsequent assessments and interventions are performed under airborne precautions. The patient must be instructed on cough etiquette and must wear a mask during transport for any medically necessary procedures outside the isolation room. Prompt notification of the local public health department and arrangement for sputum acid-fast bacilli smear and culture are essential next steps. The hierarchy of controls mandates that source containment is the most effective strategy to prevent occupational transmission of *Mycobacterium tuberculosis*.

## 핵심 개념

- **Airborne Precautions (공기매개 예방조치)** — Tuberculosis, chickenpox, measles, and other infectious diseases transmitted through tiny droplet nuclei that float in the air for long periods require infection control measures. Negative pressure isolation rooms, N95 masks, or PAPR must be used.
- **Mycobacterium tuberculosis (결핵균)** — Bacteria that cause tuberculosis. It is transmitted through the air and most commonly infects the lungs, but can also infect other organs (kidneys, bones, meninges). It is classified as an acid-fast bacillus (AFB).
- **Hemoptysis (객혈)** — Coughing up blood. This is an important symptom suggesting bleeding in the respiratory system, such as from pulmonary tuberculosis, bronchiectasis, or lung cancer.
- **Negative Pressure Isolation Room (음압격리실)** — A negative pressure room where indoor air pressure is kept lower than in hallways or adjacent areas to prevent contaminated air from escaping into clean zones. Used for isolating patients with airborne infectious diseases.
- **Night Sweats (야간발한)** — Severe sweating during sleep that soaks sleepwear or bedding. It appears as a nonspecific symptom of various systemic diseases such as tuberculosis, lymphoma, and endocrine disorders.

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