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A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?
- A. Bronchoscopy
- B. Chest X-ray
- C. TB skin test (Mantoux test)
- D. Sputum culture for acid-fast bacillus
Correct Answer: D
Rationale: The correct answer is D: Sputum culture for acid-fast bacillus. This test is the most reliable for confirming active pulmonary TB because it directly detects the presence of the Mycobacterium tuberculosis bacteria in the sputum sample. Bronchoscopy (A) may help visualize the airways but does not definitively confirm TB. Chest X-ray (B) can show characteristic findings suggestive of TB but cannot confirm the diagnosis. TB skin test (C) indicates exposure but not active disease. Sputum culture is the gold standard for diagnosing TB, as it allows for definitive identification of the bacteria.
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A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take?
- A. Obtain a sputum culture
- B. Administer a chest X-ray
- C. Monitor for fever
- D. Provide oxygen therapy
Correct Answer: A
Rationale: The correct answer is A: Obtain a sputum culture. This is essential to identify the specific pathogen causing the pneumonia in the client with AIDS. By identifying the pathogen, appropriate antibiotic therapy can be initiated promptly. Administering a chest X-ray (B) may help in evaluating the extent of pneumonia but does not address the underlying cause. Monitoring for fever (C) is important but does not provide specific information needed for targeted treatment. Providing oxygen therapy (D) may be necessary but does not address the root cause of the pneumonia.
A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the nurse take?
- A. Check the client's vital signs every 15 min during the transfusion.
- B. Obtain a blood pressure reading every 30 minutes during the transfusion.
- C. Start the transfusion at a rapid rate to improve hemoglobin levels.
- D. Check the client's vital signs every hour during the transfusion.
Correct Answer: A
Rationale: The correct answer is A: Check the client's vital signs every 15 min during the transfusion. This is crucial to monitor for any signs of transfusion reaction, such as fever, chills, or hypotension. Vital signs should be closely monitored initially and then at regular intervals to ensure the client's safety. Checking every 15 minutes allows for early detection and prompt intervention if any adverse reactions occur.
Choice B is incorrect because obtaining a blood pressure reading every 30 minutes is not as frequent as checking vital signs every 15 minutes, which is necessary for early detection of adverse reactions.
Choice C is incorrect as starting the transfusion at a rapid rate can lead to adverse reactions like fluid overload or hemolysis. Transfusions should be started at a slow rate to minimize these risks.
Choice D is incorrect because checking vital signs every hour is not frequent enough to detect early signs of transfusion reactions. Regular monitoring every 15 minutes is recommended for safety.
A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?
- A. Abdominal cramps and diarrhea
- B. Persistent cough and chest pain
- C. Flu-like symptoms and night sweats
- D. Severe fatigue and weight loss
Correct Answer: C
Rationale: The correct answer is C: Flu-like symptoms and night sweats. Initial symptoms of HIV infection often resemble flu-like symptoms such as fever, fatigue, sore throat, swollen lymph nodes, and night sweats. This occurs because the virus is rapidly replicating in the body and the immune system is reacting to it. The other choices, abdominal cramps and diarrhea (A), persistent cough and chest pain (B), and severe fatigue and weight loss (D), are more commonly associated with later stages of HIV infection or other conditions. Therefore, the nurse should include flu-like symptoms and night sweats in the explanation of initial symptoms to accurately inform the client.
A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
- A. Increased serum calcium level
- B. Decreased serum calcium level
- C. Increased white blood cell count
- D. Decreased platelet count
Correct Answer: B
Rationale: The correct answer is B: Decreased serum calcium level. In fat embolism syndrome (FES), fat globules enter the bloodstream, leading to blockages in small blood vessels. This can cause a decrease in serum calcium due to the formation of fat emboli in the pulmonary circulation, leading to hypoxia and subsequent release of inflammatory mediators that can affect calcium levels. The other choices are incorrect because in FES, there is no direct effect on serum calcium levels. Increased serum calcium levels (choice A) are not expected in FES. While increased white blood cell count (choice C) and decreased platelet count (choice D) can occur in response to inflammation or infection associated with FES, they are not specific laboratory findings for FES.
A nurse is teaching about adverse effects of anastrozole with a client who has advanced breast cancer and is postmenopausal. Which of the following adverse effects should the nurse recommend the client report to the provider?
- A. Fatigue
- B. Hot flashes
- C. Musculoskeletal pain
- D. Nausea
Correct Answer: C
Rationale: The correct answer is C: Musculoskeletal pain. Anastrozole, an aromatase inhibitor used in breast cancer treatment, can cause musculoskeletal pain as a common adverse effect. This is important to report to the provider as it may indicate musculoskeletal issues such as osteoporosis or arthritis. Fatigue (A) and hot flashes (B) are common side effects of anastrozole but not typically indicative of serious issues requiring immediate attention. Nausea (D) is also a common side effect but is usually manageable and not a significant concern unless severe. It is crucial for the nurse to prioritize musculoskeletal pain as a potential indicator of more serious complications.