Nokea
A 55-year old male patient is admitted with an active tuberculosis infection. The nurse will place the patient in precautions and will always wear when providing patient care?
- A. droplet, respirator
- B. airborne, respirator
- C. contact and airborne, surgical mask
- D. droplet, surgical mask
Correct Answer: B
Rationale: Active tuberculosis requires airborne precautions due to its transmission via respiratory droplets. A respirator (e.g., N95) is required for healthcare workers, not a surgical mask, to protect against inhaling the bacteria.
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A patient is prescribed Warfarin (Coumadin) for the treatment of a blood clot. What is the therapeutic INR range for this medication?
- A. 2--3
- B. 3--1
- C. 8--4
- D. 0.5-2.5
Correct Answer: A
Rationale: The therapeutic INR range is 2-3. It may be slightly higher if a patient is at a high risk for clot formation (ex: up to 4.5)
Which statement indicates the client with a total laryngectomy requires more teaching concerning the care of the tracheostomy?
- A. I must avoid hair spray and powders.
- B. I should take a shower instead of a tub bath.
- C. I will need to cleanse around the stoma daily.
- D. I can use an electric larynx to speak.
Correct Answer: D
Rationale: Using an electric larynx (D) is related to speech, not tracheostomy care, indicating a misunderstanding of tracheostomy management. Avoiding hair spray/powders (A), showering (B), and daily stoma cleaning (C) are correct tracheostomy care practices.
Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment?
- A. Check the amount of wall suction being applied.
- B. Assess the tubing for blood clots.
- C. Milk the tubing proximal to distal.
- D. Encourage the client to cough forcefully.
Correct Answer: A
Rationale: Excessive bubbling suggests an air leak or high suction; checking suction (A) is first. Clots (B), milking (C), and coughing (D) are secondary or inappropriate.
The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of 'impaired gas exchange.' Which is an expected outcome for this problem?
- A. Performs chest physiotherapy three (3) times a day.
- B. Able to complete activities of daily living.
- C. Ambulates in the hall several times during each shift.
- D. Alert and oriented to person, place, time, and events.
Correct Answer: D
Rationale: Alert/oriented status (D) indicates improved oxygenation from resolved gas exchange impairment. Physiotherapy (A) is an intervention, ADLs (B) and ambulation (C) are secondary outcomes.
You assist your patient with using their inhaler. The inhaler contains the medication Budesonide. Before administering the inhaler, you will want to connect what device to the inhaler to help decrease the patient from developing?
- A. Peak flow meter; pneumonia
- B. Incentive spirometer; thrush
- C. Spacer; thrush
- D. Peak flow meter; mouth sores
Correct Answer: C
Rationale: A spacer helps deliver Budesonide, an inhaled corticosteroid, more effectively to the lungs, reducing the risk of oral thrush by minimizing medication deposition in the mouth.