Nokea
A 48-year old homeless man, who is living in a local homeless shelter and is an IV drug user, has arrived to the clinic to have his PPD skin test assessed. What is considered a positive result?
- A. 5 mm induration
- B. 15 mm induration
- C. 9 mm induration
- D. 10 mm induration
Correct Answer: D
Rationale: 15 mm induration is positive in ALL people regardless of health history or risk factors. However, for patients who are homeless (living in homeless shelter) and are IV drug users, a 10 mm or more is considered positive.
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The client is diagnosed with cancer of the larynx and is to have radiation therapy to the area. Which prophylactic procedure will the nurse prepare the client for?
- A. Removal of the client's teeth and fitting for dentures.
- B. Take antiemetic medications every four (4) hours.
- C. Wear sunscreen on the area at all times.
- D. Placement of a nasogastric feeding tube.
Correct Answer: A
Rationale: Dental extraction (A) prevents radiation-induced tooth decay. Antiemetics (B), sunscreen (C), and NG tubes (D) are not prophylactic for laryngeal radiation.
Which statement is correct regarding mycobacterium tuberculosis?
- A. This bacterium is an anaerobic type of bacteria.
- B. It is an alkali bacterium that stains bright red during an acid-fast smear test.
- C. It is known as being an aerobic type of bacteria.
- D. It's an acid-fact bacterium that stains bright green during an acid-fast smear test.
Correct Answer: C
Rationale: Mycobacterium tuberculosis is AEROBIC (it thrives in conditions that are high in oxygen), and it is an ACID-FAST bacterium, which means when it is stained during an acid-fast smear it will turn BRIGHT RED.
A patient has a positive PPD skin test that shows an 8 mm induration. As the nurse you know that:
- A. The patient will need to immediately be placed in droplet precautions and started on a medication regime.
- B. The patient will need a chest x-ray and sputum culture to confirm the test results before treatment is provided.
- C. The patient will need an IGRA test to help differentiate between a latent tuberculosis infection versus an active tuberculosis infection.
- D. The patient will need to repeat the skin test in 48-72 hours to confirm the results.
Correct Answer: B
Rationale: A positive PPD test (8 mm induration) indicates TB exposure but does not confirm active disease. A chest X-ray and sputum culture are needed to differentiate latent from active TB before treatment or precautions are initiated.
Which assessment data indicate to the nurse the client diagnosed with Legionnaires' disease is experiencing a complication?
- A. The client has an elevated body temperature.
- B. The client has less than 30 mL urine output an hour.
- C. The client has a decrease in body aches.
- D. The client has an elevated white blood cell count.
Correct Answer: B
Rationale: Oliguria (<30 mL/hr, B) indicates renal failure, a serious complication of Legionnaires' disease due to systemic infection or shock. Fever (A) and elevated WBC (D) are expected in active infection, not complications. Decreased body aches (C) suggests improvement, not a complication.
Because of the client's pleural effusion and advanced lung disease, what would the nurse expect to hear when assessing the breath sounds?
- A. Wheezing in the upper lobes
- B. A friction rub posterior to the affected area
- C. Crackles over the affected area
- D. Decreased sounds over the involved area
Correct Answer: D
Rationale: Pleural effusion causes decreased breath sounds over the affected area due to fluid accumulation compressing the lung.