Nokea
A 52-year old female patient is receiving medical treatment for a possible tuberculosis infection. The patient is a U.S. resident but grew up in a foreign country. She reports that as a child she received the BCG vaccine (bacille Calmette-Guerin vaccine). Which physician's order below would require the nurse to ask the doctor for an order clarification?
- A. PPD (Mantoux test)
- B. Chest X-ray
- C. QuantiFERON-TB Gold (QFT)
- D. Sputum culture
Correct Answer: A
Rationale: The BCG vaccine can cause false-positive PPD (Mantoux) test results, making it unreliable in patients with a BCG history. The nurse should clarify this order, as an IGRA test (e.g., QuantiFERON-TB Gold) or other diagnostics are preferred.
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A patient with active tuberculosis is taking Ethambutol. As the nurse you make it priority to assess the patient's?
- A. hearing
- B. mental status
- C. vitamin B6 level
- D. vision
Correct Answer: D
Rationale: This medication can cause inflammation of the optic nerve. Therefore, it is very important the nurse asks the patient about their vision. If the patient has blurred vision or reports a change in colors, the MD must be notified immediately.
The nurse is preparing the client diagnosed with laryngeal cancer for a laryngectomy in the morning. Which intervention is the nurse's priority?
- A. Take the client to the intensive care unit for a visit.
- B. Explain that the client will need to ask for pain medication.
- C. Demonstrate the use of an antiembolism hose.
- D. Find out if the client can read and write.
Correct Answer: D
Rationale: Literacy (D) ensures post-laryngectomy communication (e.g., writing), a priority. ICU visit (A), pain requests (B), and TED hose (C) are secondary.
Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax?
- A. Gentle bubbling in the suction compartment.
- B. No fluctuation (tidaling) in the water-seal compartment.
- C. The drainage compartment has 250 mL of blood.
- D. The client is able to deep breathe without any pain.
Correct Answer: B
Rationale: No tidaling (B) indicates lung re-expansion, showing effective hemothorax treatment. Bubbling (A) suggests air leak, drainage (C) is expected, and pain-free breathing (D) is secondary.
When the client asks why the physician chose this particular drug to treat the pneumonia, which response by the nurse is best?
- A. The sensitivity report showed the organism is often killed by penicillin.
- B. Most viral infections respond well when treated with penicillin drugs.
- C. Penicillin is one of the safest yet most effective antibiotics.
- D. All antibiotics are similar; the choice of drug is not that important.
Correct Answer: A
Rationale: Penicillin is chosen based on the sensitivity report, indicating that the pneumococcal bacteria are susceptible to it.
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.