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A client is receiving oxygen therapy via a nasal cannula. The nurse should explain that this method of oxygen delivery does which of the following?
- A. Delivers a specific concentration of oxygen constantly
- B. Delivers a high concentration of oxygen
- C. Delivers a low concentration of oxygen
- D. Restricts the client's ability to eat, speak, or drink
Correct Answer: A
Rationale: A nasal cannula is a device used for delivering supplemental oxygen to patients. It delivers a specific concentration of oxygen constantly, typically ranging from 1-6 liters per minute. This method is effective for patients who require low to moderate levels of oxygen. Choices B and C are incorrect because a nasal cannula does not deliver a high concentration of oxygen and is not considered a low concentration delivery method. Choice D is incorrect because a nasal cannula does not restrict the client's ability to eat, speak, or drink; it allows them to perform these activities while receiving oxygen therapy.
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A nurse in a clinic is caring for a client who came to be tested for tuberculosis (TB) after a close family member tested positive. The nurse should know that which of the following is a diagnostic tool used to screen for TB?
- A. Sputum culture for acid-fast bacillus (AFB)
- B. Mantoux skin test
- C. BCG vaccine
- D. Chest X-ray
Correct Answer: B
Rationale: The Mantoux skin test, also known as the tuberculin skin test, is a diagnostic tool used to screen for tuberculosis (TB). It involves injecting a small amount of tuberculin under the top layer of the skin on the forearm and then checking for a reaction within 48-72 hours. This test helps identify individuals who have been exposed to the TB bacteria. Sputum culture for acid-fast bacillus (AFB) is used to confirm TB diagnosis in individuals suspected of having active TB. The BCG vaccine is used to prevent severe forms of tuberculosis in high-risk individuals but is not a diagnostic tool. While a chest X-ray can show signs of active TB disease, it is not a primary diagnostic tool for screening purposes.
A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the client's troponin levels, the client asks what this blood test will show. The nurse should explain that troponin is
- A. an enzyme that indicates damage to brain, heart, and skeletal muscle tissues.
- B. a protein whose levels reflect the risk for coronary artery disease.
- C. a heart muscle protein that appears in the bloodstream when there is damage to the heart.
- D. a protein that helps transport oxygen throughout the body.
Correct Answer: C
Rationale: The correct answer is that troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Troponin is a specific marker for heart muscle damage, particularly seen in conditions like myocardial infarction. Choice A is incorrect as troponin is not an enzyme that indicates damage to brain and skeletal muscle tissues. Choice B is incorrect as troponin is not a protein whose levels reflect the risk for coronary artery disease; it indicates heart muscle damage. Choice D is incorrect as troponin is not a protein that helps transport oxygen throughout the body; its presence in the bloodstream is specific to heart muscle damage.
A nurse in a community health center is assessing the results of the purified protein derivative (PPD) testing she performed to screen for tuberculosis (TB). She interprets which of the following results as positive for a 6-year-old client with no risk factors for TB?
- A. 4-mm erythema
- B. 5-mm induration
- C. 10-mm wheal
- D. 15-mm induration
Correct Answer: D
Rationale: The correct answer is D: 15-mm induration. In PPD testing, an induration (hardened raised area) of 15 mm or more is considered positive for TB in individuals with no risk factors. Choices A, B, and C are incorrect because an erythema of 4 mm, induration of 5 mm, or wheal of 10 mm are not indicative of a positive TB test result in a low-risk individual. Therefore, the interpretation of a 15-mm induration would lead the nurse to consider the test positive for TB in this case.
A client with angina pectoris is being taught about starting therapy with nitroglycerin (Nitrostat) tablets. The nurse should instruct the client to take the medication
- A. after each meal and at bedtime.
- B. every 15 minutes during an acute attack.
- C. at the first indication of chest pain.
- D. with 8 oz of water.
Correct Answer: C
Rationale: Nitroglycerin (Nitrostat) tablets are used to relieve chest pain associated with angina. The client should take the medication at the first indication of chest pain to help dilate blood vessels and improve blood flow to the heart muscle. Choice A is incorrect because nitroglycerin should not be scheduled after each meal or at bedtime. Choice B is incorrect as taking the medication every 15 minutes during an acute attack is excessive and not recommended. Choice D is incorrect because while it is important to take nitroglycerin with water, the timing of water intake is not as critical as taking the medication at the first sign of chest pain.
In preparation for the discharge of a client with peripheral arterial disease (PAD), the nurse should include which of the following instructions?
- A. Apply a heating pad on a low setting to help relieve leg pain.
- B. Adjust the thermostat so that the environment is warm.
- C. Wear antiembolic stockings during the day.
- D. Rest with the legs above heart level.
Correct Answer: D
Rationale: Resting with the legs above heart level is important for clients with peripheral arterial disease (PAD) to promote better circulation and reduce leg pain. Applying a heating pad on a low setting can actually worsen symptoms by causing burns or increasing blood flow to the area, which is not recommended for PAD. While keeping the environment warm is generally beneficial, it is not a specific instruction for managing PAD. Antiembolic stockings are typically used for preventing blood clots in hospitalized patients and may not be directly related to managing PAD at home.