A patient is admitted with active tuberculosis (TB). The nurse should question a healthcare provider's order to discontinue airborne precautions unless which assessment finding is documented?
- A. Chest x-ray shows no upper lobe infiltrates.
- B. TB medications have been taken for 6 months.
- C. Mantoux testing shows an induration of 10 mm.
- D. Three sputum smears for acid-fast bacilli are negative.
Correct Answer: D
Rationale: The correct answer is D: Three sputum smears for acid-fast bacilli are negative. Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. This finding is crucial for discontinuing airborne precautions. Choice A is incorrect because chest x-rays do not determine the presence of active TB for transmission precautions. Choice B is not directly related to the infectiousness of TB; completing a 6-month course of medication is important for treatment but does not confirm the absence of active disease or infectiousness. Choice C is not relevant to assessing infectiousness; Mantoux testing measures exposure to TB but does not confirm the absence of active infection or infectiousness.
You may also like to solve these questions
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6°F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?
- A. Codeine
- B. Guaifenesin (Robitussin)
- C. Acetaminophen (Tylenol)
- D. Piperacillin/tazobactam (Zosyn)
Correct Answer: D
Rationale: The correct answer is Piperacillin/tazobactam (Zosyn). Early initiation of antibiotic therapy is crucial in cases of community-acquired pneumococcal pneumonia to reduce mortality. While providing symptomatic relief with medications like Codeine for cough, Guaifenesin for mucus clearance, and Acetaminophen for fever and pain is important, the priority should be to start antibiotic therapy to target the underlying infection. Piperacillin/tazobactam is an appropriate choice for treating severe community-acquired pneumonia caused by pneumococcal organisms.
After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?
- A. Teach about drug-resistant TB treatment
- B. Ask the patient whether medications have been taken as directed
- C. Schedule the patient for directly observed therapy three times weekly
- D. Discuss with the healthcare provider the need for the patient to use an injectable antibiotic
Correct Answer: B
Rationale: The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed. Teaching about drug-resistant TB treatment (Choice A) is premature without knowing the current medication compliance status. Scheduling directly observed therapy (Choice C) assumes non-compliance without confirming it first. Discussing the need for an injectable antibiotic (Choice D) is premature and not necessarily indicated without assessing the current medication adherence.
A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
- A. Assist with active range of motion (ROM).
- B. Observe for agitation and paranoia.
- C. Give muscle relaxants as needed to reduce spasms.
- D. Use simple words and phrases to explain procedures.
Correct Answer: A
Rationale: In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.
The pediatric nurse caring for a 3-year-old child with cerebral palsy (CP) prepares a home care teaching plan for the caregivers on discharge. Which items will the nurse include in the teaching plan? (Select one that does not apply.)
- A. Apply splints and braces to facilitate muscle control.
- B. Buy toys that are appropriate for the child's abilities.
- C. Encourage the child to perform self-care tasks.
- D. Use skeletal muscle relaxants for short-term control.
Correct Answer: D
Rationale: When developing a discharge teaching plan for a child with cerebral palsy (CP), the nurse should focus on strategies to enhance the child's independence and functional abilities. Choices A, B, and C are appropriate interventions to include in the teaching plan for a child with CP. Applying splints and braces can help facilitate muscle control and improve body functioning. Buying toys that are appropriate for the child's abilities can promote engagement and development. Encouraging the child to perform self-care tasks fosters independence and skill development. However, the use of skeletal muscle relaxants for short-term control is not typically a part of routine care for pediatric patients with CP. These medications are usually reserved for specific situations and are not a standard component of home care teaching plans for children with CP.
A nurse is caring for a patient with peripheral vascular disease (PVD). The patient
complains of burning and tingling of the hands and feet and cannot tolerate touch of any
kind. Which of the following is the most likely explanation for these symptoms?
- A. Inadequate tissue perfusion leading to nerve damage.
- B. Fluid overload leading to compression of nerve tissue.
- C. Sensation distortion due to psychiatric disturbance.
- D. Inflammation of the skin on the hands and feet.
Correct Answer: A
Rationale: Patients with the peripheral vascular disease often sustain nerve damage as a result of
inadequate tissue perfusion. Ischemic rest pain is more worrisome; it refers to pain in the
extremity that is due to a combination of PVD and inadequate perfusion. Ischemic rest
pain often is exacerbated by poor cardiac output. The condition is often partially or fully
relieved by placing the extremity in a dependent position, so that perfusion is enhanced by
the effects of gravity.