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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: A
Rationale: For high-risk individuals (e.g., homeless, IV drug users), a PPD induration of ≥5 mm is considered positive due to their increased risk of TB exposure and progression.
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To evaluate the significance of the client's bleeding, which additional assessment is most important for the nurse to make at this time?
- A. Count the pulse rate.
- B. Listen to heart sounds.
- C. Check the pupillary response.
- D. Measure the chest expansion.
Correct Answer: D
Rationale: Measuring chest expansion helps assess for complications like pneumothorax, which could cause bleeding post-bronchoscopy.
A patient is receiving continuous IV Heparin for anticoagulation therapy for the treatment of a DVT. In order for this medication to have a therapeutic effect on the patient, the aPTT should be?
- A. 0.5-2.5 times the normal value range
- B. 2-3 times the normal value range
- C. 1.5-2.5 times the normal value range
- D. 1-3.5 times the normal value range
Correct Answer: C
Rationale: An aPTT should be 1.5-2.5 times the normal value range for Heparin to achieve a therapeutic effect in a patient to prevent blood clots. If the aPTT is too low, blood clots can form. If the aPTT is too high, bleeding can occur.
You're educating a patient how to use a peak flow meter to help monitor the status of their asthma. Which statement by the patient demonstrates they understand how to use the device?
- A. This device will help keep my lungs strong so I don't have another asthma attack.
- B. I will inhale as hard as I can while using the device.
- C. I will use this device at the same time, either in the morning or before bedtime, and compare the readings with my personal best reading.
- D. I will notify the doctor if my peak flow rating is 90% or more than my personal best peak flow.
Correct Answer: C
Rationale: Correct use involves measuring peak flow at consistent times and comparing to personal best to monitor asthma control. Inhaling is incorrect, and a high reading is not a concern.
An adult is admitted with chronic obstructive pulmonary disease [COPD]. The nurse notes that he has neck vein distention and slight peripheral edema. The practical nurse notifies the registered nurse and continues frequent assessments because the nurse knows that these signs signal the onset of which of the following?
- A. Pneumothorax
- B. Cor pulmonale
- C. Cardiogenic shock
- D. Left-sided heart failure
Correct Answer: B
Rationale: Neck vein distention and peripheral edema indicate right-sided heart failure, or cor pulmonale, caused by pulmonary hypertension in COPD.
A 72 year-old male patient who is diagnosed with bilateral lower lobe pneumonia is admitted to your unit. The patient has a history of systolic heart failure and arthritis. On assessment, you note the patient has a respiratory rate of 21 , oxygen saturation $93 \%$ on $2 \mathrm{~L}$ nasal cannula, is alert & oriented, and has a productive cough with green/yellowish sputum. Which of the following nursing interventions will you provide to this patient based on your assessment findings and the patient's diagnosis? Select-all-that-apply:
- A. Keep head-of-the-bed less than 30 degrees at all times.
- B. Collect sputum cultures.
- C. Encourage 3L of fluids a day to keep secretions thin.
- D. Encourage incentive spirometer usage
- E. Provide education about receiving the Pneumovax vaccine annually.
Correct Answer: B,D
Rationale: Sputum cultures identify the causative organism, and incentive spirometer use promotes lung expansion. Head-of-bed <30 degrees increases aspiration risk, 3L fluids may overload heart failure patients, and Pneumovax is not annual.