Nokea
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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Your patient with a diagnosis of latent tuberculosis infection needs a bronchoscopy. During transport to endoscopy, the patient will need to wear?
- A. N95 mask
- B. Surgical mask
- C. No special PPE is needed
- D. Face mask with shield
Correct Answer: B
Rationale: Patients with latent tuberculosis are not contagious and have no symptoms, but during procedures like bronchoscopy that may generate aerosols, a surgical mask is worn to prevent potential spread if the infection is active.
When suctioning the airway of a client with a tracheostomy, the nurse applies suction for no longer than how many seconds?
- A. 5 to 7
- B. 10 to 12
- C. 15 to 20
- D. 25 to 30
Correct Answer: B
Rationale: Suctioning for 10 to 12 seconds minimizes the risk of hypoxia and mucosal trauma.
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.
A 79-year-old client is admitted to the hospital with a diagnosis of pneumococcal pneumonia. The client has dyspnea. The client's temperature is 102°F, respirations are 36, and pulse is 92. Bed rest is ordered for this client primarily to:
- A. promote thoracic expansion.
- B. prevent the development of atelectasis.
- C. decrease metabolic needs.
- D. prevent infection of others.
Correct Answer: C
Rationale: Bed rest reduces metabolic and oxygen demands in a client with pneumonia and dyspnea, aiding recovery.
An adult has a chest drainage system. The client's wife reports to the nurse that her husband is restless. The nurse enters the room just in time to see him pull out his chest tube. The most appropriate initial action for the nurse to take is to:
- A. go get petrolatum gauze and apply over the wound.
- B. place her/his hand firmly over the wound.
- C. apply a sterile 4x4 dressing.
- D. reinsert the chest tube.
Correct Answer: B
Rationale: Placing a hand firmly over the wound prevents air from entering the pleural space, which could cause a pneumothorax.