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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Which clinical manifestation should the nurse expect to assess in the client recently diagnosed with COPD?
- A. Clubbing of the client's fingers.
- B. Infrequent respiratory infections.
- C. Chronic sputum production.
- D. Nonproductive hacking cough.
Correct Answer: C
Rationale: Chronic sputum production (C) is a hallmark of COPD (chronic bronchitis). Clubbing (A) is late-stage, infections (B) are frequent, and nonproductive cough (D) is atypical.
The client is admitted to the outpatient surgery center for a bronchoscopy to rule out cancer of the lung. Which information should the nurse teach?
- A. The test will confirm the results of the MRI.
- B. The client can eat and drink immediately after the test.
- C. The HCP can do a biopsy of the tumor through the scope.
- D. There is no discomfort associated with this procedure.
Correct Answer: C
Rationale: Bronchoscopy allows biopsy (C) to diagnose lung cancer. It doesn’t confirm MRI (A), requires NPO post-procedure (B), and causes discomfort (D).
The nurse identified the client problem 'decreased cardiac output' for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care?
- A. Monitor the client's arterial blood gases.
- B. Assess skin color and temperature.
- C. Check the client for signs of bleeding.
- D. Keep the client in the Trendelenburg position.
Correct Answer: A
Rationale: ABGs (A) monitor oxygenation, supporting cardiac output in PE. Skin color (B) is secondary, bleeding (C) relates to anticoagulation, and Trendelenburg (D) is contraindicated.
The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis (Tb). Which statement indicates the need for radiological evaluation instead of skin testing?
- A. The client's first skin test indicates a purple flat area at the site of injection.
- B. The client's second skin test indicates a red area measuring four (4) mm.
- C. The client's previous skin test was read as positive.
- D. The client has never shown a reaction to the tuberculin medication.
Correct Answer: C
Rationale: A prior positive TB skin test (C) indicates exposure, requiring CXR to assess active disease, not repeat skin testing. Purple area (A) is normal, 4 mm (B) is negative, and no reaction (D) warrants testing.
A patient is ordered at 1400 to take Theophylline. You're assessing the patient's morning lab results and note that the Theophylline level drawn this morning reads: $15 \mathrm{mcg} / \mathrm{mL}$. You're next nursing action is to?
- A. Administer the dose at 1400 as ordered
- B. Notify the physician for further orders
- C. Hold the 1400 dose
- D. Collect another blood sample to confirm the level
Correct Answer: A
Rationale: A Theophylline level of 15 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the dose should be administered as ordered . No further action is needed.