Before We Start
Standard precautions — the foundation that applies to everyone
Before learning about transmission-based precautions, understand that Standard Precautions apply to EVERY patient, EVERY time, regardless of diagnosis or known infection status.
Standard precautions are based on the assumption that every patient's blood, body fluids, secretions, and excretions (except sweat) may contain transmissible pathogens. You don't wait for a positive test to protect yourself.
Standard Precautions include — for ALL patients:
• Hand hygiene — before and after every patient contact, before putting on gloves, after removing gloves. This is the single most important infection control measure.
• Gloves — when contact with blood, body fluids, mucous membranes, or non-intact skin is anticipated
• Gown — when clothing/skin contact with blood or body fluids is anticipated
• Mask and eye protection — when splashing of blood or body fluids is likely
• Safe sharps handling and disposal
• Proper handling of soiled patient equipment and linens
Transmission-based precautions are added ON TOP of standard precautions when a patient has a known or suspected infection that spreads by a specific route.
The Three Types
Contact · Droplet · Airborne — and the diseases in each
Contact Precautions
PPE: Gloves + Gown (put on before entering, remove before leaving)
Contact precautions prevent the spread of organisms transmitted by direct contact (touching the patient) or indirect contact (touching contaminated surfaces or equipment).
Key diseases requiring Contact Precautions:
• MRSA (Methicillin-resistant Staphylococcus aureus)
• VRE (Vancomycin-resistant Enterococcus)
• C. diff (Clostridioides difficile) — special note: use soap and water, NOT alcohol-based hand sanitizer (alcohol doesn't kill C. diff spores)
• Scabies and lice
• RSV (Respiratory Syncytial Virus)
• Wound infections with resistant organisms
• Large, uncontained draining wounds
Room requirements: Private room preferred. If not available, cohort with patient who has same infection.
💊 C. diff = soap and water only. Alcohol hand sanitizer does NOT kill C. diff spores. This is a classic NCLEX trick question.
Droplet Precautions
PPE: Surgical mask (when within 3 feet of patient)
Droplet precautions prevent spread of large respiratory droplets (greater than 5 microns) that travel short distances (3–6 feet) and do not remain airborne for extended periods. Droplets are produced when a patient coughs, sneezes, talks, or during procedures.
Key diseases requiring Droplet Precautions:
• Influenza (flu)
• Pertussis (whooping cough)
• Meningitis — specifically meningococcal (Neisseria meningitidis). NOT all meningitis requires droplet precautions — only meningococcal.
• Mumps
• Rubella (German measles — note: rubeola/regular measles = Airborne)
• Streptococcal pharyngitis (strep throat)
• Diphtheria
Key fact: Surgical mask is sufficient — N95 is NOT required. The droplets are large and fall quickly. A standard surgical mask blocks them.
💊 Rubella (German measles) = Droplet. Rubeola (regular measles) = Airborne. The similar names are a classic NCLEX trap. Rubeola goes with the MTV mnemonic for Airborne.
Airborne Precautions
PPE: N95 respirator (fit-tested) + Negative pressure room
Airborne precautions prevent spread of tiny droplet nuclei (less than 5 microns) that remain suspended in the air for long periods and travel far distances. Simply being in the same room — even hours after the patient has left — can transmit these pathogens.
MTV — the three diseases requiring Airborne Precautions:
• M — Measles (Rubeola)
• T — Tuberculosis (TB)
• V — Varicella (Chickenpox) and disseminated Zoster (shingles)
Room requirements: Negative pressure room (air flows IN from hallway, not out — keeps particles in the room). Door must remain closed. Limited visitors.
N95 respirator: Must be fit-tested before use. A surgical mask is NOT sufficient for Airborne precautions.
Patient transport: When transporting an Airborne patient, the patient wears a surgical mask (to contain particles). The nurse still wears the N95.
💊 MTV = Measles, TB, Varicella. These three and only these three need Airborne (N95 + negative pressure). Everything else is Contact or Droplet.
Quick Reference
PPE summary by precaution type
Contact: Gloves + Gown
Put on before entering. Remove before leaving. Hand hygiene after removing. Private room preferred. MRSA, VRE, C. diff (soap and water only), Scabies, RSV.
Droplet: Surgical Mask (within 3 feet)
Surgical mask when within 3 feet of patient. Private room preferred. Influenza, Pertussis, Meningococcal meningitis, Mumps, Rubella, Strep pharyngitis.
Airborne: N95 + Negative Pressure Room
Fit-tested N95 respirator. Negative pressure private room. Door closed at all times. Patient wears surgical mask during transport. MTV: Measles, TB, Varicella.
Some diseases require COMBINATION precautions
Varicella (chickenpox) requires both Airborne AND Contact — it spreads through airborne droplet nuclei AND through contact with the vesicles.
SARS-CoV-2 (COVID-19) — protocols varied but generally required both Droplet and Contact, with Airborne for aerosol-generating procedures.
🏥 Clinical Scenario — Matching Precautions to Patients
You are receiving four new admissions. What precautions does each require?
Pt 1
68-year-old with suspected active TB. CXR shows upper lobe cavitation. Currently awaiting AFB sputum results. → Airborne precautions immediately. Do not wait for test results. Suspected TB = Airborne precautions. N95 + negative pressure room. Notify charge nurse for room assignment.
Pt 2
34-year-old with influenza A, fever 39.5°C, productive cough. → Droplet precautions. Surgical mask when within 3 feet. Private room. Standard precautions for any hands-on care.
Pt 3
55-year-old with MRSA wound infection, draining surgical incision. → Contact precautions. Gloves and gown before entering. Private room preferred. Hand hygiene with soap and water or alcohol (MRSA is killed by alcohol — unlike C. diff).
Pt 4
72-year-old with C. diff diarrhea — third episode this admission. → Contact precautions + soap and water ONLY. This is the critical C. diff distinction. Alcohol-based hand sanitizer does NOT kill C. diff spores. Dedicated equipment (stethoscope, blood pressure cuff) stays in the room.
📌 NCLEX Application
Transmission precautions are consistently high-yield on NCLEX.
Classic NCLEX questions:
• "What PPE does the nurse don before entering the room of a patient with TB?" → N95 + gown + gloves (Airborne + Standard)
• "A patient with C. diff — what hand hygiene does the nurse use?" → Soap and water (not alcohol)
• "A patient with varicella — what precautions?" → Airborne AND Contact
• "A patient with meningococcal meningitis — what precautions?" → Droplet (surgical mask)
The MTV mnemonic is the fastest path to the Airborne answer. If it's not Measles, TB, or Varicella — it's not Airborne (with rare exceptions like SARS, smallpox, monkeypox).
⚠️ The Two Classic NCLEX Traps
Trap 1 — Rubella vs. Rubeola:
Rubella (German measles, 3-day measles) = Droplet precautions. Surgical mask.
Rubeola (regular measles, red measles) = Airborne precautions. N95 + negative pressure.
The similar names are intentionally confusing. Remember: Rubeola is in MTV. Rubella is not.
Trap 2 — C. diff and alcohol hand sanitizer:
Alcohol-based hand sanitizer kills most bacteria and viruses — but C. diff forms spores that alcohol cannot penetrate. Soap and water physically removes the spores. This is tested repeatedly because it contradicts the general preference for alcohol rub.
When C. diff appears in an NCLEX question about hand hygiene — the answer is always soap and water.
✓ Quick Self-Test — Precaution Category
Identify the precaution type for each condition:
1. Influenza
2. MRSA wound infection
3. Active tuberculosis
4. Varicella (chickenpox)
5. C. diff colitis
6. Meningococcal meningitis
7. Rubella (German measles)
Answers:
1. Droplet (surgical mask)
2. Contact (gloves + gown)
3. Airborne (N95 + negative pressure)
4. Airborne + Contact (N95 + negative pressure + gloves + gown)
5. Contact (gloves + gown + soap/water hand hygiene only)
6. Droplet (surgical mask)
7. Droplet (surgical mask) — NOT airborne; Rubeola is airborne, not Rubella
Next Lesson
Vital Signs — Normal Ranges and When to Act
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