Nokea
A patient has a positive PPD skin test that shows an 8 mm induration. As the nurse you know that:
- A. The patient will need to immediately be placed in droplet precautions and started on a medication regime.
- B. The patient will need a chest x-ray and sputum culture to confirm the test results before treatment is provided.
- C. The patient will need an IGRA test to help differentiate between a latent tuberculosis infection versus an active tuberculosis infection.
- D. The patient will need to repeat the skin test in 48-72 hours to confirm the results.
Correct Answer: B
Rationale: A positive PPD result does NOT necessarily mean the patient has an active infection of TB. The patient will need a chest x-ray and sputum culture to determine if mycobacterium tuberculosis is present and then treatment will be based on those results. The IGRA test does NOT differentiate between LTBI or an active TB infection. Patients are placed in airborne precautions (NOT droplet) if they have ACTIVE TB.
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The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse?
- A. The UAP keeps the chest tube below chest level.
- B. The UAP has the chest tube attached to suction.
- C. The UAP allowed the client out of the bed.
- D. The UAP uses a bedside commode for the client.
Correct Answer: B
Rationale: Suction during ambulation (B) restricts mobility and risks dislodgement, requiring intervention. Below chest level (A), ambulation (C), and commode (D) are appropriate.
After levalbuterol hydrochloride (Xopenex) administration, which client symptom does the nurse evaluate as a side effect of the medication?
- A. Respiratory rate of 28 breaths/minute
- B. Heart rate of 96 beats/minute
- C. Blood pressure of 100/60 mm Hg
- D. Drowsiness
Correct Answer: B
Rationale: Levalbuterol, a beta-agonist, commonly causes an increased heart rate as a side effect due to its stimulatory effects.
The nurse is preparing the plan of care for the client who had a pleurodesis. Which collaborative intervention should the nurse include?
- A. Monitor the amount and color of drainage from the chest tube.
- B. Perform a complete respiratory assessment every two (2) hours.
- C. Administer morphine sulfate, an opioid analgesic, intravenously.
- D. Keep a sterile dressing and bottle of sterile normal saline at the bedside.
Correct Answer: A
Rationale: Pleurodesis involves sclerosing the pleural space to prevent fluid reaccumulation, often requiring a chest tube. Monitoring drainage amount and color (A) is a collaborative intervention to assess procedure success and detect complications. Respiratory assessment (B) and morphine administration (C) are nursing or medical orders, not collaborative. Keeping sterile supplies (D) is preparatory, not a primary intervention.
The case manager is arranging a care planning meeting regarding the care of a 65-year-old client diagnosed with adult-onset asthma. Which health-care disciplines should participate in the meeting? Select all that apply.
- A. Nursing.
- B. Pharmacy.
- C. Social work.
- D. Occupational therapy.
- E. Speech therapy.
Correct Answer: A,B,C
Rationale: Nursing (A), pharmacy (B), and social work (C) address asthma management, medications, and social needs. Occupational (D) and speech (E) therapies are less relevant.
Before discharging a client with fractured ribs from the emergency department, which instruction is most important for the nurse to give the client?
- A. Avoid coughing to prevent further injury.
- B. Take deep breaths periodically.
- C. Apply heat to the chest daily.
- D. Sleep in a prone position.
Correct Answer: B
Rationale: Taking deep breaths periodically prevents atelectasis and pneumonia, which are risks with fractured ribs due to shallow breathing.