Nokea
A patient receiving medical treatment for an active tuberculosis infection asks when she can starting going out in public again. You respond that she is no longer contagious when:
- A. She has 3 negative sputum cultures
- B. Her signs and symptoms improve
- C. She has completed the full medication regime
- D. Her chest x-ray is normal
- E. She has been on tuberculosis medications for about 3 weeks
Correct Answer: A
Rationale: A patient with active TB is considered non-contagious after three consecutive negative sputum cultures, indicating no viable bacteria. Symptom improvement, medication duration, or normal X-rays alone do not confirm non-contagiousness.
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Aside from the characteristics of the client's cough, which other pertinent assessment finding should the nurse document?
- A. Family history of respiratory disease
- B. Current vital signs
- C. Appearance of respiratory secretions
- D. Any self-treatment measures used by the client
Correct Answer: C
Rationale: The appearance of respiratory secretions (color, consistency) provides critical information about the infection's severity and type.
Because of the client's pleural effusion and advanced lung disease, what would the nurse expect to hear when assessing the breath sounds?
- A. Wheezing in the upper lobes
- B. A friction rub posterior to the affected area
- C. Crackles over the affected area
- D. Decreased sounds over the involved area
Correct Answer: D
Rationale: Pleural effusion causes decreased breath sounds over the affected area due to fluid accumulation compressing the lung.
Which information should the nurse include in the teaching plan for the mother of a child diagnosed with cystic fibrosis (CF)? Select all that apply.
- A. Perform postural drainage and percussion every four (4) hours.
- B. Modify activities to accommodate daily physiotherapy.
- C. Increase fluid intake to one (1) liter daily to thin secretions.
- D. Recognize and report signs and symptoms of respiratory infections.
- E. Avoid anyone suspected of having an upper respiratory infection.
Correct Answer: A,B,D,E
Rationale: Postural drainage (1) helps clear mucus in CF. Modifying activities for physiotherapy (2) ensures adherence. Recognizing infection signs (4) and avoiding respiratory infections (5) prevent exacerbations. One liter of fluid (3) is insufficient for children; fluid needs vary by age and size.
Which response by the nurse is most appropriate at this time?
- A. The pain will lessen in a few minutes.
- B. I will stay with you until the physician comes.
- C. Why would you even think something like that?
- D. Are your financial affairs in order?
Correct Answer: B
Rationale: Staying with the client provides emotional support and ensures prompt intervention during a suspected pulmonary embolism.
Which household measurement should the nurse use when teaching the client how to self-administer the prescribed amount of liquid cough syrup?
- A. One ounce
- B. One tablespoon
- C. One teaspoon
- D. One capful
Correct Answer: C
Rationale: A 5 mL dose of liquid cough syrup is equivalent to one teaspoon, a standard household measurement.