Nokea
An alarm beeps notifying you that one of your patient's oxygen saturation is reading $89 \%$. You arrive to the patient's room, and see the patient comfortably resting in bed watching television. The patient is already on $2 \mathrm{~L}$ of oxygen via nasal cannula. The patient is admitted for COPD exacerbation. Your next nursing action would be:
- A. Continue to monitor the patient
- B. Increase the patient's oxygen level to $3 \mathrm{~L}$
- C. Notify the doctor for further orders
- D. Turn off the alarm settings
Correct Answer: A
Rationale: In COPD, oxygen saturation of 88-92% is acceptable to avoid suppressing the hypoxic drive. Since the patient is comfortable, continue monitoring . Increasing oxygen or notifying the doctor is unnecessary unless symptoms worsen.
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A patient has a positive PPD skin test that shows an 8 mm induration. As the nurse you know that:
- A. The patient will need to immediately be placed in droplet precautions and started on a medication regime.
- B. The patient will need a chest x-ray and sputum culture to confirm the test results before treatment is provided.
- C. The patient will need an IGRA test to help differentiate between a latent tuberculosis infection versus an active tuberculosis infection.
- D. The patient will need to repeat the skin test in 48-72 hours to confirm the results.
Correct Answer: B
Rationale: A positive PPD result does NOT necessarily mean the patient has an active infection of TB. The patient will need a chest x-ray and sputum culture to determine if mycobacterium tuberculosis is present and then treatment will be based on those results. The IGRA test does NOT differentiate between LTBI or an active TB infection. Patients are placed in airborne precautions (NOT droplet) if they have ACTIVE TB.
The nurse observes the unlicensed assistive personnel (UAP) entering an airborne isolation room and leaving the door open. Which action is the nurse's best response?
- A. Close the door and discuss the UAP's action after coming out of the room.
- B. Make the UAP come back outside the room and then reenter, closing the door.
- C. Say nothing to the UAP but report the incident to the nursing supervisor.
- D. Enter the client's room and discuss the matter with the UAP immediately.
Correct Answer: A
Rationale: Closing the door (A) maintains airborne precautions, and discussing later ensures education without disrupting care. Reentering (B) is unnecessary, reporting (C) escalates prematurely, and discussing inside (D) risks exposure.
Which datum requires immediate intervention by the nurse for the client diagnosed with asbestosis?
- A. The client develops an S3 heart sound.
- B. The client has clubbing of the fingers.
- C. The client is fatigued in the afternoon.
- D. The client has basilar crackles in all lobes.
Correct Answer: A
Rationale: An S3 heart sound (A) indicates heart failure, a serious complication in asbestosis due to pulmonary hypertension, requiring immediate intervention. Clubbing (B) is a chronic finding, not acute. Fatigue (C) is common but not urgent. Basilar crackles (D) are expected in asbestosis and less critical than cardiac issues.
A client comes to the clinic with a bloody nose. Which instruction is most appropriate?
- A. Sit up with your head tilted forward. Grasp the soft part of your nose firmly between your thumb and forefinger.'
- B. Lay down and tilt your head backward. Grasp the end of your nose between your fingers.'
- C. Sit up and lean backwards. Put pressure on the side of your nose with your hand.'
- D. Lie down with your head lower than your feet. Grasp as much of your nose as possible between your fingers.'
Correct Answer: A
Rationale: Sitting with the head tilted forward and grasping the soft part of the nose prevents aspiration of blood and effectively stops bleeding.
Your patient, who is receiving Pyrazinamide, report stiffness and extreme pain in the right big toe. The site is extremely red, swollen, and warm. You notify the physician and as the nurse you anticipated the doctor will order?
- A. Calcium level
- B. Vitamin B6 level
- C. Uric acid level
- D. Amylase level
Correct Answer: C
Rationale: Pyrazinamide can cause hyperuricemia, leading to gout symptoms (pain, redness, swelling in joints like the big toe). The physician will likely order a uric acid level to confirm this side effect.