Nokea
A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Encourage between-meal snacks.
- B. Monitor temperature every 4 hours.
- C. Provide oral care every 4 hours.
- D. Report any new onset of cough.
Correct Answer: C
Rationale: Oral colonization by gram-negative bacteria is a risk factor for healthcare-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the UAP.
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A client has the diagnosis of valley fever accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on?
- A. Intravenous amphotericin B.
- B. Long-term anti-inflammatories.
- C. No specific treatment.
- D. Oral fluconazole (Diflucan).
Correct Answer: D
Rationale: Valley fever, or coccidioidomycosis, is a fungal infection. The presence of joint and muscle pain indicates a moderate infection that needs treatment with antifungal medications like oral fluconazole.
A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate?
- A. Arrange for immediate hospitalization.
- B. Facilitate polymerase chain reaction testing.
- C. Have the client produce a sputum sample.
- D. Obtain two sets of blood cultures.
Correct Answer: B
Rationale: Polymerase chain reaction testing is used to diagnose pertussis, which this client is showing manifestations of. This is the most appropriate action to confirm the diagnosis.
A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important?
- A. Are any family members also ill?
- B. Have you traveled recently?
- C. How long have you been ill?
- D. What is your occupation?
Correct Answer: D
Rationale: Inhalation anthrax is rare and is an occupational hazard among people who work with animal wool, bone meal, hides, and such, such as tanners and veterinarians. Inhalation anthrax in someone without an occupational risk is considered a bioterrorism event and must be reported to authorities immediately.
A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best?
- A. Collect a sputum sample for culture by deep suctioning.
- B. Instruct the client that antibiotics will be needed for 60 days.
- C. Place the client on Airborne Precautions immediately.
- D. Tell the client that directly observed therapy is needed.
Correct Answer: B
Rationale: This client has manifestations of early inhalation anthrax. For treatment, after IV antibiotics are finished, oral antibiotics are continued for at least 60 days, making this the best action.
A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.)
- A. Blood urea nitrogen (BUN): 19 mg/dL.
- B. International normalized ratio (INR): 6.3.
- C. Prothrombin time: 35 seconds.
- D. Serum sodium: 120 mEq/L.
- E. White blood cell (WBC) count: 72,000/mm³.
Correct Answer: B,C
Rationale: Rifampin can cause liver damage, evidenced by the client's high INR and prothrombin time, which indicate coagulopathy due to liver dysfunction. The BUN, WBC count, and sodium levels are not directly related to this condition.