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: A patient with ACTIVE TB is contagious. The bacterium, mycobacterium tuberculosis which causes TB, is so small that it can stay suspended in the air for hours to days. Therefore, the nurse will place the patient in AIRBORNE precautions. In addition, a special mask must be worn called a respirator (as referred to as an N95 mask.....a surgical mask does NOT work with this condition).
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The client diagnosed with lung cancer has been told the cancer has metastasized to the brain. Which intervention should the nurse implement?
- A. Discuss implementing an advance directive.
- B. Explain the use of chemotherapy for brain involvement.
- C. Teach the client to discontinue driving.
- D. Have the significant other make decisions for the client.
Correct Answer: C
Rationale: Brain metastasis impairs cognition, making driving unsafe (C). Advance directives (A), chemotherapy (B), and proxy decisions (D) are secondary or inappropriate.
Which statement by the client diagnosed with a pulmonary embolus indicates the discharge teaching is effective?
- A. I am going to use a regular-bristle toothbrush.
- B. I will take antibiotics prior to having my teeth cleaned.
- C. I can take enteric-coated aspirin for my headache.
- D. I will wear a Medic Alert band at all times.
Correct Answer: D
Rationale: A Medic Alert band (D) ensures emergency awareness of PE/anticoagulation. Multiple Choice toothbrushes (A) risk bleeding, antibiotics (B) are for endocarditis, and aspirin (C) increases bleeding.
Until the client can be examined later that morning, which advice by the nurse would be most helpful?
- A. Sucking on ice chips should help.
- B. Rest your voice.
- C. Massage your throat.
Correct Answer: B
Rationale: Resting the voice reduces strain on the vocal cords, which is beneficial for laryngitis and helps prevent further irritation.
Which problem is appropriate for the nurse to identify for the client who is one (1) day postoperative thoracotomy?
- A. Alteration in comfort.
- B. Altered level of consciousness.
- C. Alteration in elimination pattern.
- D. Knowledge deficit.
Correct Answer: A
Rationale: Pain (alteration in comfort, A) is a common issue post-thoracotomy due to surgical incision and chest tube placement, making it the most appropriate nursing diagnosis on day one. Altered consciousness (B) is not typical unless complications arise. Elimination issues (C) are less immediate. Knowledge deficit (D) is relevant later for discharge teaching.
The physician orders an acid-fast bacilli sputum culture smear on a patient with possible tuberculosis. How will you collect this?
- A. Collect 2 different sputum specimens 12 hours apart
- B. Collect 3 different sputum specimens (one in the morning, afternoon, and at night)
- C. Collect 3 different sputum specimens on 3 different days
- D. Collect 2 different sputum specimens on 2 different days
Correct Answer: C
Rationale: For acid-fast bacilli sputum culture, standard protocol requires collecting three sputum specimens on three consecutive days, typically in the morning, to maximize detection of Mycobacterium tuberculosis.