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: Patients who have received the BCG vaccine will have a false positive on a PPD (Mantoux test), which is the tuberculin skin test. The BCG vaccine is a vaccine to prevent TB. It is given in foreign countries to children to prevent TB. Therefore, the person has already been exposed to the bacteria via vaccine and will have a false positive. A QuantiFERON-TB Gold test is a better option for this patient. It is a blood test.
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The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse?
- A. The client's pulse oximeter reading is 92%.
- B. The client's arterial blood gas level is 74.
- C. The client has SOB when walking to the bathroom.
- D. Rusty colored sputum.
Correct Answer: D
Rationale: Rusty sputum (D) suggests hemoptysis or infection, a critical finding in end-stage COPD. SpO2 92% (A), PaO2 74 (B), and SOB (C) are expected but less urgent.
Which statement by the client best indicates that the client understands the rationale for the direct laryngoscopy?
- A. The test will tell if my hoarseness is caused by tracheal polyps.
- B. The physician says that hoarseness can lead to bronchitis.
- C. I need to have the test because hoarseness is a symptom of laryngeal cancer.
- D. The physician wants to see if my hoarseness is because of enlarged tonsils.
Correct Answer: C
Rationale: Persistent hoarseness can be a symptom of laryngeal cancer, and direct laryngoscopy is used to visualize the larynx for abnormalities like tumors.
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.
The client diagnosed with lung cancer is in an investigational program and receiving a vaccine to treat the cancer. Which information regarding investigational regimens should the nurse teach?
- A. Investigational regimens provide a better chance of survival for the client.
- B. Investigational treatments have not been proven to be helpful to clients.
- C. Clients will be paid to participate in an investigational program.
- D. Only clients who are dying qualify for investigational treatments.
Correct Answer: B
Rationale: Investigational treatments (B) lack proven efficacy, requiring informed consent. Better survival (A), payment (C), and terminal status (D) are incorrect.
Which nursing action is essential before suctioning the client with a tracheostomy tube?
- A. Preoxygenating the client
- B. Maintaining the head in a flexed position
- C. Cleaning around the stoma
- D. Removing the inner cannula
Correct Answer: A
Rationale: Preoxygenating the client prevents hypoxia during suctioning, which can temporarily reduce oxygen intake.