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A client is suspected of having a diagnosis of pulmonary tuberculosis. The nurse should assess the client for which signs/symptoms of tuberculosis?
- A. High fever and chest pain
- B. Increased appetite, dyspnea, and chills
- C. Weight gain, insomnia, and night sweats
- D. Low-grade fever, fatigue, and productive cough
Correct Answer: D
Rationale: The client with pulmonary tuberculosis generally has a productive or nonproductive cough, anorexia and weight loss, fatigue, low-grade fever, chills and night sweats, dyspnea, hemoptysis, and chest pain. Breath sounds may reveal crackles.
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The nurse collecting data from the client is providing instructions regarding a new prescription for disulfiram. Which datum is important for the nurse to obtain before beginning the administration of this medication?
- A. When the last full meal was consumed
- B. When the last alcoholic drink was consumed
- C. If the client has a history of hyperthyroidism
- D. If the client has a history of diabetes insipidus
Correct Answer: B
Rationale: Disulfiram may be used as an adjunct treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. Therefore, it is important for the nurse to determine when the last alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is also contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication.
A client with the diagnosis of leukemia is receiving chemotherapy. When the registered nurse (RN) notes that the white blood cell (WBC) count is 4000 mm^3 (4 x 10^9/L), the new nurse caring for the client is informed about the results. Which intervention identified by the new nurse indicates a need for further teaching?
- A. Restricting visitors with colds or respiratory infections
- B. Removing all live plants, flowers, and stuffed animals in the client's room
- C. Placing the client on a low-bacteria diet that excludes raw foods and vegetables
- D. Padding the side rails and removing all hazardous and sharp objects from the room
Correct Answer: D
Rationale: Padding the side rails and removing all hazardous and sharp objects from the environment would be instituted if the client is at risk for bleeding. This client is at risk for infection. When the WBC count is less than 5000 mm^3 (5 x 10^9/L), visitors should be screened for the presence of infection, and any visitors or staff with colds or respiratory infections should not be allowed in the client's room. All live plants, flowers, and stuffed animals are removed from the client's room. The client is placed on a low-bacteria diet that excludes raw fruits and vegetables.
As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do?
- A. Place the client in a wheelchair to protect their safety in the clinic.
- B. Remove the cane from the client to protect their safety.
- C. Teach the client about the proper length of a cane.
- D. Have the client use a wheelchair rather than the cane.
Correct Answer: C
Rationale: Educating the client about the proper cane length (typically where the handle reaches the wrist when the arm is at the side) promotes safety and proper use without unnecessarily restricting mobility.
You are caring for a client who has just had a thoracentesis. Which complication should you be aware of during the immediate post-operative period of time?
- A. Infection
- B. Pneumothorax
- C. Aspiration
- D. Dyspnea
Correct Answer: B
Rationale: Pneumothorax is a potential complication of thoracentesis due to the risk of lung puncture during the procedure, requiring immediate monitoring.
A newborn infant receives the first dose of hepatitis B vaccine within 12 hours of birth. The nurse instructs the parent regarding the immunization schedule for this vaccine and should tell the parent that the second vaccine is administered at which time periods?
- A. 3 years of age and then during the adolescent years
- B. 8 months of age and then 1 year after the initial dose
- C. 6 months of age and then 8 months after the initial dose
- D. 1 to 2 months of age and then 6 months after the initial dose
Correct Answer: D
Rationale: The vaccination schedule for an infant whose mother tests negative for hepatitis B consists of a series of 3 immunizations given at 0 months (birth), 1 to 2 months of age, and then 6 months after the initial dose. An infant whose mother tests positive receives hepatitis B immune globulin along with the first dose of the hepatitis vaccine within 12 hours of birth.