Nokea
The nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that Mycobacterium tuberculosis is cultured. How should the nurse correctly analyze these results?
- A. The results are positive for active tuberculosis.
- B. The results indicate a less virulent strain of tuberculosis.
- C. The results are inconclusive until a repeat sputum specimen is sent.
- D. The results are unreliable unless the client has also had a positive tuberculin skin test (TST).
Correct Answer: A
Rationale: Culture of Mycobacterium tuberculosis from sputum or other body secretions or tissue confirms the diagnosis of active tuberculosis.
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The nurse is preparing to initiate an intravenous nitroglycerin drip on a client who has experienced an acute myocardial infarction. In the absence of an invasive (arterial) monitoring line, the nurse prepares to have which piece of equipment for use at the bedside to help assure the client's safety?
- A. Defibrillator
- B. Pulse oximeter
- C. Central venous pressure (CVP) tray
- D. Noninvasive blood pressure monitor
Correct Answer: D
Rationale: Nitroglycerin dilates arteries and veins (vasodilator), causing peripheral blood pooling, thus reducing preload, afterload, and myocardial workload. This action accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of an arterial monitoring line, the nurse should have a noninvasive blood pressure monitor for use at the bedside.
As part of cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which location?
- A. At the left midclavicular line at the fifth intercostal space
- B. At the left midclavicular line at the third intercostal space
- C. To the right of the left midclavicular line at the fifth intercostal space
- D. To the right of the left midclavicular line at the third intercostal space
Correct Answer: A
Rationale: The point of maximal impulse (PMI), where the apical pulse is palpated, is normally located in the fourth or fifth intercostal space, at the left midclavicular line. Options 2, 3, and 4 are not descriptions of the location for palpation of the apical pulse.
The nurse has administered approximately half of a high-cleansing enema when the client reports pain and cramping. Which nursing action is appropriate?
- A. Reassuring the client that those sensations will subside
- B. Discontinuing the enema and notifying the primary health care provider
- C. Raising the enema bag so that the solution can be introduced quickly
- D. Clamping the tubing for 30 seconds and restarting the flow at a slower rate
Correct Answer: D
Rationale: The enema fluid should be administered slowly. If the client complains of pain or cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema administration and stopping the flow temporarily, if necessary, will decrease the likelihood of intestinal spasm and premature ejection of the solution. The client's report of pain and cramping should not be ignored. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum. There is no need to discontinue the enema and notify the primary health care provider at this time.
The nurse provides information to a client with a colostomy. When discussing measures to help manage colostomy odors, the nurse will encourage the client to regularly consume which foods? Select all that apply.
- A. Parsley
- B. Yogurt
- C. Buttermilk
- D. Cucumbers
- E. Cauliflower
- F. Cranberry juice
Correct Answer: A,B,C,F
Rationale: The nurse should provide information about foods and measures that will prevent odor from a colostomy. Parsley, yogurt, buttermilk, and cranberry juice will prevent odor. Charcoal filters, pouch deodorizers, or placement of a breath mint in the pouch will also eliminate odors. Foods that cause flatus and thus odor, including broccoli, Brussels sprouts, cabbage, cauliflower, cucumbers, mushrooms, and peas, should be avoided.
A magnetic resonance imaging (MRI) scan is prescribed for a client with a suspected brain tumor. Which prescription should the nurse anticipate will be prescribed for the client before the procedure?
- A. An opioid
- B. A sedative
- C. A corticosteroid
- D. An antihistamine
Correct Answer: B
Rationale: An MRI scan is a noninvasive diagnostic test that visualizes the body's tissues, structure, and blood flow. For an MRI, the client is positioned on a padded table and moved into a cylinder-shaped scanner. Relaxation techniques, an eye mask, and sedation are used before the procedure to reduce claustrophobic effects; however, because the client must remain very still during the scan, the nurse avoids oversedating the client to ensure client cooperation. There is no useful purpose for administering an opioid, corticosteroid, or antihistamine.