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A thoracentesis was performed on an adult client. After the procedure, the client has hemoptysis and a pulse of 80, respirations of 28, and temperature of 99°F. Which of these is of greatest concern to the nurse?
- A. Hemoptysis
- B. Respirations of 28
- C. Pulse of 80
- D. Temperature of 99°F
Correct Answer: A
Rationale: Hemoptysis is the only abnormal finding and indicates potential bleeding or lung injury, which is of greatest concern post-thoracentesis. The other vital signs are within normal ranges for someone who has undergone an invasive procedure.
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The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client?
- A. A red area is a positive reading that means the client has tuberculosis.
- B. The skin test is the only procedure needed to diagnose tuberculosis.
- C. A positive reading means exposure to the tuberculosis bacilli.
- D. Do not get another skin test for one (1) year if the skin test is positive.
Correct Answer: C
Rationale: A positive TB skin test (C) indicates exposure to TB bacilli, not active disease, requiring further testing (e.g., chest X-ray). Redness alone (A) is not diagnostic; induration is measured. The skin test (B) is not definitive for diagnosis. Annual testing (D) may be needed in high-risk groups.
A 48-year old homeless man, who is living in a local homeless shelter and is an IV drug user, has arrived to the clinic to have his PPD skin test assessed. What is considered a positive result?
- A. 5 mm induration
- B. 15 mm induration
- C. 9 mm induration
- D. 10 mm induration
Correct Answer: A
Rationale: For high-risk individuals (e.g., homeless, IV drug users), a PPD induration of ≥5 mm is considered positive due to their increased risk of TB exposure and progression.
Select all the factors regarding a deep vein thrombosis that are included in Virchow's Triad:
- A. Hypocoagulability
- B. Atherosclerosis
- C. Endothelial damage
- D. Stasis of venous blood
- E. Excessive coagulability
- F. Increased venous blood flow
Correct Answer: C,D,E
Rationale: Virchow's Triad details the THREE factors (hence why it called a triad) for blood clot formation within the vessel. Remember 'SHE': Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage.
A 52-year old female patient is receiving medical treatment for a possible tuberculosis infection. The patient is a U.S. resident but grew up in a foreign country. She reports that as a child she received the BCG vaccine (bacille Calmette-Guerin vaccine). Which physician's order below would require the nurse to ask the doctor for an order clarification?
- A. PPD (Mantoux test)
- B. Chest X-ray
- C. QuantiFERON-TB Gold (QFT)
- D. Sputum culture
Correct Answer: A
Rationale: The BCG vaccine can cause false-positive PPD (Mantoux) test results, making it unreliable in patients with a BCG history. The nurse should clarify this order, as an IGRA test (e.g., QuantiFERON-TB Gold) or other diagnostics are preferred.
Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax?
- A. Gentle bubbling in the suction compartment.
- B. No fluctuation (tidaling) in the water-seal compartment.
- C. The drainage compartment has 250 mL of blood.
- D. The client is able to deep breathe without any pain.
Correct Answer: B
Rationale: No tidaling (B) indicates lung re-expansion, showing effective hemothorax treatment. Bubbling (A) suggests air leak, drainage (C) is expected, and pain-free breathing (D) is secondary.