A patient has a PPD skin test (Mantoux test). As the nurse you tell the patient to report back to the office in so the results can be interpreted?
- A. 24-48 hours
- B. 12-24 hours
- C. 48-72 hours
- D. 24-72 hours
Correct Answer: C
Rationale: The patient should report back in 48-72 hours. If they fail to, the test must be repeated.
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You're providing discharge teaching to a patient who was admitted for pneumonia. You are discussing measures the patient can take to prevent pneumonia. Which of the following statements by the patient indicates they did NOT understand your education material?
- A. I'll use hand sanitizer regularly while I'm out in public.'
- B. It is important I don't receive the Pneumovax vaccine since I'm already immune to pneumonia.'
- C. I will try to avoid large crowds of people during the peak of flu season.'
- D. It is important I try to quit smoking.'
Correct Answer: B
Rationale: The statement about not receiving the Pneumovax vaccine is incorrect, as vaccination is recommended to prevent pneumococcal pneumonia, and prior infection doesn't confer immunity. Other options reflect correct preventive measures.
If a client is allergic to penicillin, the nurse should anticipate a hypersensitivity response to which other group of antibiotics?
- A. Aminoglycosides such as kanamycin (Kantrex)
- B. Tetracyclines such as doxycycline (Vibramycin)
- C. Cephalosporins such as ceftriaxone (Rocephin)
- D. Fluoroquinolones such as ciprofloxacin (Cipro)
Correct Answer: C
Rationale: Cephalosporins have a similar beta-lactam structure to penicillin, increasing the risk of cross-reactivity in penicillin-allergic clients.
The client diagnosed with tuberculosis has been treated with antitubercular medications for six (6) weeks. Which data would indicate the medications have been effective?
- A. A decrease in the white blood cells in the sputum.
- B. The client's symptoms are improving.
- C. No change in the chest X-ray.
- D. The skin test is now negative.
Correct Answer: B
Rationale: Improved symptoms (B) after six weeks of TB treatment (e.g., reduced cough, fever) indicate medication efficacy. WBCs in sputum (A) are not a standard measure. Chest X-ray changes (C) lag behind clinical improvement. The skin test (D) remains positive post-exposure, regardless of treatment.
The client diagnosed with respiratory distress has arterial blood gases of pH 7.45, Paco2 54, Hco3 25, Pao2 52. Which should the nurse implement? Select all that apply.
- A. Apply oxygen via nonrebreather mask.
- B. Call the rapid response team (RRT).
- C. Elevate the head of the bed.
- D. Stay with the client.
- E. Notify the health-care provider (HCP).
Correct Answer: A,B,C,D,E
Rationale: PaO2 52 and PaCO2 54 indicate severe hypoxia; apply nonrebreather (A), call RRT (B), elevate HOB (C), stay with client (D), and notify HCP (E) are all critical.
Which position is best for the client to be in while the nurse prepares to assess breath sounds?
- A. Sitting
- B. Standing
- C. Lying on the back
- D. Lying on the side
Correct Answer: A
Rationale: Sitting upright allows optimal lung expansion, making it easier to assess breath sounds accurately in a client with asthma.