Nokea
A woman who had a tuberculosis test three days ago reports to the nurse to have the test read. Which finding, if present, indicates a positive result and a need for referral and follow-up?
- A. A red area 12 mm in diameter
- B. A raised area 10 mm in diameter
- C. Itching at the injection site
- D. A rash on the arm near the test site
Correct Answer: B
Rationale: A raised (indurated) area >10 mm indicates a positive TB skin test, requiring follow-up for potential latent or active TB.
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An adult is scheduled for a paracentesis. What should the nurse plan to do immediately before the procedure is started?
- A. Give the client a full glass of water
- B. Have the client empty his/her bladder
- C. Ask the client to empty his/her bowels
- D. Administer diazepam (Valium) as ordered
Correct Answer: B
Rationale: Emptying the bladder before paracentesis prevents accidental puncture of the bladder during needle insertion into the abdominal cavity. Water intake, bowel emptying, or sedation are not immediate pre-procedure priorities.
The nurse is caring for a client who is receiving antibiotic therapy and develops Clostridioides difficile colitis. Which of the following infection-control precautions should the nurse implement? Select all that apply.
- A. Disinfect surfaces using a diluted bleach solution
- B. Perform hand hygiene using an alcohol-based hand sanitizer
- C. Wear a face mask
- D. Wear a protective gown
- E. Wear nonsterile gloves
Correct Answer: A,D,E
Rationale: Bleach disinfection (A), gowns (D), and gloves (E) are required for C. difficile, which is spore-forming. Alcohol sanitizers (B) are ineffective against spores, and masks (C) are not routinely needed.
The nurse is monitoring a client who had an esophagogastroduodenoscopy 2 hours ago. Which finding requires an immediate report to the registered nurse?
- A. Blood pressure drop from 122/88 mm Hg to 106/72 mm Hg
- B. Gag reflex has not returned
- C. Sore throat when swallowing
- D. Temperature spike to 101.2 F (38.4 C)
Correct Answer: D
Rationale: A temperature spike to 101.2 F (D) suggests possible perforation or infection, requiring immediate reporting. BP drop (A) is mild, absent gag reflex (B) is expected, and sore throat (C) is normal post-procedure.
An adult is admitted to the long-term care facility. She had a cerebrovascular accident and no longer needs acute care. The client has left side hemiplegia. Because of the type of deficit the client has, the nurse knows that this woman is at increased risk for which of the following?
- A. Speech and language deficits
- B. Slow and cautious behavior
- C. Difficulty with visual-spatial relationships
- D. Hearing deficits
Correct Answer: C
Rationale: Left hemiplegia from a right brain CVA increases risk for visual-spatial deficits, as the right hemisphere processes spatial awareness, unlike speech (left hemisphere), behavior, or hearing.
The nurse is caring for a client with a tracheostomy who has an order to begin oral intake. Which of the following actions should the nurse take to decrease the client's risk for aspiration?
- A. Fully inflate the tracheostomy cuff before the client begins to eat.
- B. Encourage the client to use a straw when drinking fluids.
- C. Instruct the client to tilt the head back when swallowing
- D. Provide thickened liquids for the client.
Correct Answer: D
Rationale: Thickened liquids (D) reduce aspiration risk by slowing transit. Inflating the cuff (A) is not always necessary, straws (B) may increase risk, and tilting the head back (C) worsens aspiration.