Nokea
A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5 mm of erythema without induration. What is the best initial nursing action?
- A. Document negative results in the client's medical record
- B. Repeat the test immediately on the opposite forearm
- C. Notify the healthcare provider for further evaluation
- D. Schedule the worker for a chest X-ray
Correct Answer: A
Rationale: Erythema without induration is not considered a positive result. Documentation of negative findings is appropriate.
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Adverse reactions to angiotensin-converting enzyme inhibitors (ACEIs) include the following EXCEPT
- A. hypotension
- B. hypokalemia
- C. maculopapular rash
- D. renal toxicity
Correct Answer: B
Rationale: ACEIs can cause hyperkalemia, not hypokalemia.
Acetazolamide:
- A. Is used in the management of renal tubular acidosis
- B. Causes hypokalaemia
- C. Is usually given intravenously
- D. Inhibits the action of carbonic anhydrase
Correct Answer: D
Rationale: Inhibits the action of carbonic anhydrase: Acetazolamide works by inhibiting carbonic anhydrase, reducing the reabsorption of bicarbonate in the kidneys and helping with conditions like glaucoma, metabolic alkalosis, and altitude sickness.
A male client complains of pain in his right calf, and the nurse determines that his calf is edematous and deep red. What intervention has the highest priority?
- A. Tell the client to remain in bed
- B. Apply warm compresses to the affected leg.
- C. Administer pain medication as prescribed.
- D. Encourage the client to elevate the affected leg.
Correct Answer: A
Rationale: The symptoms suggest deep vein thrombosis (DVT). Bed rest prevents dislodgment of the clot, reducing the risk of pulmonary embolism.
The most common coronary artery anomaly in Tetralogy of Fallot is
- A. Left anterior descending artery from right aortic sinus
- B. Single coronary artery from right aortic sinus
- C. Single coronary artery from left aortic sinus
- D. Left circumflex coronary artery from right aortic sinus
Correct Answer: A
Rationale: The most common coronary artery anomaly in Tetralogy of Fallot is the left anterior descending artery arising from the right aortic sinus.
The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin (Lanoxin). Which statement by the parent indicates a need for further instruction?
- A. “If my child vomits after the medication administration, I will repeat the dose.â€
- B. “I will not mix the medication with food.â€
- C. “I will take my child’s pulse before administering the medication.â€
- D. “If more than one dose is missed, I will call the provider.â€
Correct Answer: A
Rationale: Repeating the dose after vomiting can lead to digoxin toxicity, which is dangerous. The parent should be instructed to contact the healthcare provider if vomiting occurs after administration.