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 test (8 mm induration) indicates TB exposure but does not confirm active disease. A chest X-ray and sputum culture are needed to differentiate latent from active TB before treatment or precautions are initiated.
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The nurse observes the client sitting on the side of the bed with the arms propped on the over-bed table. The chest is barrel shaped and the client is breathing though lips spaced close together and is exhaling slowly. Which concept is priority for this client?
- A. Mobility.
- B. Nutrition.
- C. Activity intolerance.
- D. Oxygenation.
Correct Answer: D
Rationale: Tripod position, barrel chest, and pursed-lip breathing (D) indicate COPD with oxygenation as the priority. Mobility (A), nutrition (B), and activity (C) are secondary.
The term 'blue bloaters' is used to describe patients with?
- A. Pulmonary hypertension
- B. Left-sided heart failure
- C. Chronic Bronchitis
- D. Emphysema
Correct Answer: C
Rationale: Blue bloaters' describes chronic bronchitis patients, who present with cyanosis ('blue') and edema ('bloating') due to hypoxemia and right heart failure. Emphysema patients are often called 'pink puffers.'
The nurse is completing the admission assessment on a 13-year-old client diagnosed with an acute exacerbation of asthma. Which signs and symptoms would the nurse expect to find?
- A. Fever and crepitus.
- B. Rales and hives.
- C. Dyspnea and wheezing.
- D. Normal chest shape and eupnea.
Correct Answer: C
Rationale: Asthma exacerbation causes dyspnea and wheezing (C) from bronchoconstriction. Fever/crepitus (A), rales/hives (B), and normal breathing (D) are unrelated or incorrect.
Which priority intervention should the nurse implement for the client diagnosed with coal workers' pneumoconiosis?
- A. Monitor the client's intake and output.
- B. Assess for black-streaked sputum.
- C. Monitor the white blood cell count daily.
- D. Assess the client's activity level every shift.
Correct Answer: B
Rationale: Black-streaked sputum (B) is a hallmark of coal workers' pneumoconiosis due to coal dust deposition, making its assessment a priority to confirm disease impact. Intake/output (A) is non-specific. Daily WBC counts (C) are unnecessary unless infection is suspected. Activity level (D) is secondary to symptom assessment.
The nurse observes the unlicensed assistive personnel (UAP) removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement?
- A. Praise the UAP because this prevents the client from tripping on the oxygen tubing.
- B. Place the oxygen back on the client while sitting in the bathroom and say nothing.
- C. Explain to the UAP in front of the client oxygen must be left in place at all times.
- D. Discuss the UAP's action with the charge nurse so appropriate action can be taken.
Correct Answer: B
Rationale: COPD clients need continuous oxygen; replacing it (B) corrects the error safely. Praising (A) is incorrect, explaining in front of client (C) is unprofessional, and escalating (D) is premature.