Nokea
A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?
- A. An induration measuring 10 mm
- B. An induration measuring 5 mm
- C. A reddened area measuring 10 mm
- D. A reddened area measuring 5 mm
Correct Answer: A
Rationale: The correct answer is A: An induration measuring 10 mm. An induration of 10 mm or greater is considered a positive result for a tuberculin skin test in individuals who are at higher risk for tuberculosis. This indicates exposure to the tuberculosis bacteria and an immune response. Choices B, C, and D are incorrect because the presence of redness or a smaller induration size does not meet the criteria for a positive test result. Redness alone does not signify a positive result, and a smaller induration size is not indicative of a positive test. It is important to interpret tuberculin skin tests accurately to guide further testing and treatment decisions.
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A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the swelling of the epiglottis can rapidly obstruct the airway, leading to respiratory distress or failure. Intubation is crucial to secure the airway and ensure adequate oxygenation. Obtaining a throat culture (B) may delay necessary intervention. Suctioning the oropharynx (C) can trigger spasm and worsen the obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?
- A. Monitor blood pressure every 2 hr.
- B. Attach an inline filter to the IV tubing
- C. Protect the IV bag from exposure to light.
- D. Keep calcium gluconate at the client's bedside.
Correct Answer: C
Rationale: The correct answer is C: Protect the IV bag from exposure to light. Nitroprusside is light-sensitive and can degrade when exposed to light, leading to the formation of toxic metabolites. By protecting the IV bag from light exposure, the nurse ensures the medication's stability and prevents potential harm to the client. Monitoring blood pressure every 2 hours (Choice A) is a standard practice for clients receiving nitroprusside but is not the most critical action. Attaching an inline filter to the IV tubing (Choice B) is important to prevent particulate matter from entering the client's bloodstream but is not specific to nitroprusside administration. Keeping calcium gluconate at the client's bedside (Choice D) is unrelated to nitroprusside administration and is not necessary for this situation.
A nurse is teaching a client about advance directive. Which of the following statements by the client indicates an understanding of the teaching?
- A. A living will is a document that includes my wishes about health care decisions.'
- B. My provider will make my health care decisions if I complete advance directives.'
- C. Advance directives outline who inherits my material possessions in the event of my death.'
- D. My partner needs to be present as a witness when I sign a living will.'
Correct Answer: A
Rationale: The correct answer is A because it accurately defines a living will as a document stating the client's healthcare wishes. This shows understanding of an advance directive's purpose. Option B is incorrect because advance directives empower the client, not the provider, to make healthcare decisions. Option C is incorrect as advance directives focus on healthcare, not material possessions. Option D is incorrect as witnesses don't need to be partners, just competent adults.
A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia. Which of the following actions should the nurse take?
- A. Encourage the client to drink low-protein supplements
- B. Tell the client to drink two glasses of water with meals
- C. Serve the client's largest meal in the evening
- D. Provide the client with cold foods rather than hot foods
Correct Answer: D
Rationale: The correct answer is D: Provide the client with cold foods rather than hot foods. Cold foods may be more appealing to a client experiencing anorexia due to radiation therapy, as they often have less strong smells and flavors that can trigger nausea. Cold foods can also help soothe any oral mucositis or mouth sores that may be present. Encouraging the client to eat cold foods can help increase their overall intake and provide necessary nutrients.
Choice A is incorrect because low-protein supplements may not be sufficient in providing necessary nutrients for the client. Choice B is incorrect as simply drinking water with meals may not address the underlying issue of anorexia. Choice C is incorrect as there is no evidence to suggest that serving the largest meal in the evening will improve the client's appetite.
A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?
- A. Contact the charge nurse to see if the prescription was changed
- B. Complete an incident report and place it in the client's medical record
- C. Submit a written warning for the nurse involved in the incident
- D. Compare the current infusion with the prescription in the client's medication record
Correct Answer: D
Rationale: The correct answer is D: Compare the current infusion with the prescription in the client's medication record. This is the best course of action as it allows the nurse to verify the accuracy of the IV infusion against the prescribed treatment plan. By cross-referencing the current infusion with the prescription in the client's medication record, the nurse can identify any discrepancies and take appropriate actions to ensure the client's safety and well-being.
Choice A is incorrect because contacting the charge nurse may not provide the necessary information to verify the accuracy of the IV infusion. Choice B is incorrect as completing an incident report is premature without first verifying the discrepancy. Choice C is inappropriate and punitive without a proper investigation. Choices E, F, and G are not provided in the question, so they are irrelevant.