3.4 Transmission-Based Precautions

Matching the Precaution to the Route

The NCLEX-PN repeatedly asks the LPN/LVN to pair a specific organism with the correct precaution, PPE, and room. Memorize the three categories cold — these are high-frequency, low-ambiguity points.

The Three Categories

All three are added to Standard Precautions, never substituted for them. A memory device many students use is "MRS WEE" for Contact (Multidrug-resistant organisms, Respiratory infections like RSV, Skin infections, Wound infections, Enteric C. diff, Eye infection/conjunctivitis), "SPIDERMAN" for Droplet (Sepsis/meningitis, Pertussis, Influenza, Diphtheria, German measles/rubella, Mumps, Adenovirus, Neisseria meningitidis), and "My Chicken Hez TB" for Airborne (Measles, Chickenpox/varicella, Herpes zoster disseminated, TB). You do not need the mnemonics to pass, but you must reliably match organism to route.

Contact Precautions

Use for organisms spread by direct or indirect contact: MRSA, VRE, C. difficile, scabies, impetigo, RSV, conjunctivitis, and large draining wounds. Don gown and gloves before entering the room and remove them before leaving, use dedicated single-patient equipment (stethoscope, blood-pressure cuff, thermometer) or disinfect shared equipment between patients, and limit transport. For C. diff specifically, use soap and water for hand hygiene because alcohol does not kill spores, and a dilute bleach-based disinfectant is required to clean the environment.

A frequent question theme is the LPN who removes gown and gloves only after stepping into the hallway — this is wrong; PPE comes off inside the room (with the mask the exception for airborne).

Droplet Precautions

Use for influenza, pertussis (whooping cough), bacterial meningitis (Neisseria meningitidis, Haemophilus influenzae type b), mumps, rubella, diphtheria, adenovirus, and group A streptococcal pharyngitis. Wear a surgical mask within about 6 feet of the patient; no special air handling or negative pressure is required, the door may remain open, and the patient wears a surgical mask during transport. A high-yield distinction: droplet particles are large (greater than about 5 microns), travel only a short distance, and fall to surfaces quickly, which is why a surgical mask and spatial distance suffice.

Bacterial meningitis is droplet, but the patient can usually be removed from precautions after 24 hours of effective antibiotics.

Airborne Precautions

Use for tuberculosis, measles (rubeola), and varicella (chickenpox). Place the patient in an Airborne Infection Isolation Room (AIIR):

• Negative pressure (air flows in, not out)
• 6-12 air changes per hour, exhausted outdoors or through a HEPA filter
• Door kept closed, pressure monitored
• Staff wear a fit-tested N95 respirator or PAPR; the patient wears a surgical mask during unavoidable transport (the patient never wears the N95).

A key safety point: the N95 must be fit-tested and seal-checked each use, and staff who cannot achieve a seal (e.g., facial hair) need a powered air-purifying respirator (PAPR). For measles and varicella, only immune staff (vaccinated or previously infected) should care for the patient when possible, because the airborne risk to a susceptible caregiver is high.

Combining Precautions

Duration and the Isolated Patient

Precautions continue until criteria are met — for example, TB until three negative sputum acid-fast bacilli smears on different days, pertussis until 5 days of effective antibiotics, influenza while symptomatic per policy, and varicella until all lesions have crusted over. The provider, not the nurse, writes the order to discontinue precautions, but the LPN advocates for removal once criteria are met so the patient is not isolated longer than necessary.

Isolation carries real psychosocial harm: studies link it to anxiety, depression, loneliness, perceived stigma, and even less frequent provider visits. The LPN counters this by explaining the reason for isolation in plain language to patient and family, reassuring them that care quality is unchanged, spending unhurried time in the room, encouraging phone and video contact, supplying diversional activities, and being alert to signs of depression. Teaching visitors the correct PPE and hand-hygiene steps also reduces transmission and the patient's sense of being avoided.

Worked Example

A patient with productive cough, night sweats, and weight loss is admitted with suspected pulmonary TB. The correct placement is a negative-pressure AIIR with the door closed, with staff in fit-tested N95s — not a semi-private room and not an open-door room for observation.

Common NCLEX-PN Traps

• Choosing an N95 for droplet conditions like influenza (only a surgical mask is needed).
• Forgetting that varicella and disseminated zoster need both Airborne and Contact.
• Leaving the AIIR door open.
• Using only Standard Precautions for a C. diff patient.