Nokea
An elderly client has a 17-mm induration after a tuberculin skin test. Based on this result, which statement is most accurate?
- A. The client has a false-positive reaction due to advanced age
- B. The client has a tuberculosis infection
- C. The client has active tuberculosis disease
- D. The client must be isolated immediately
Correct Answer: B
Rationale: A 17-mm induration in an elderly client indicates TB infection, as the threshold is ≥10 mm for high-risk groups. It doesn't confirm active disease, which requires further testing (e.g., chest X-ray). False positives are possible but not assumed based on age alone. Isolation isn't required without active disease.
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The nurse is caring for a client who has a pulmonary embolism. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. dyspnea
- B. chest pain
- C. tachypnea
- D. hypoxemia
- E. bradycardia
- F. tracheal deviation
Correct Answer: A,B,C,D
Rationale: Pulmonary embolism obstructs pulmonary arteries, causing dyspnea, chest pain, tachypnea, and hypoxemia. Bradycardia is unlikely; tachycardia is typical. Tracheal deviation is associated with tension pneumothorax, not embolism.
The nurse is teaching a client about communicable diseases and explains that a portal of entry is:
- A. a vector.
- B. a source, like contaminated water.
- C. food.
- D. the respiratory system.
Correct Answer: D
Rationale: The path by which a microorganism enters the body is the portal of entry. A vector is a carrier of disease, a source (like bad water or food) can be a reservoir of disease.
A nurse is teaching a class for new parents at a local community center. The nurse would stress that what is most hazardous for an 8 month-old child?
- A. Riding in a car
- B. Falling off a bed
- C. An electrical outlet
- D. Eating peanuts
Correct Answer: D
Rationale: Eating peanuts. Asphyxiation due to foreign materials in the respiratory tract is the leading cause of death in children younger than 6 years of age.
The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply.
- A. Check gastric residual every 12 hours
- B. Keep head of the bed at ≥30 degrees
- C. Maintain endotracheal cuff pressure
- D. Monitor for abdominal distension every 4 hours
- E. Use caution when administering sedatives
Correct Answer: B,C,D,E
Rationale: Elevating the head of the bed (≥30 degrees) reduces reflux, proper cuff pressure seals the airway, monitoring distension detects feed intolerance, and cautious sedation prevents respiratory depression. Residual checks every 4-6 hours are standard, not 12.
The nurse is caring for a client with Kawasaki disease. Which of the following actions would be a priority for the nurse to take?
- A. Monitor the client for gallop heart sounds and decreased urine output.
- B. Provide a quiet, nonstimulating, restful environment for the client.
- C. Apply cool compresses to the skin of the client's hands and feet.
- D. Offer the client soft foods and adequate amounts of clear liquids.
Correct Answer: B
Rationale: A quiet, restful environment reduces irritability and stress in Kawasaki disease, promoting recovery. Monitoring heart sounds/urine output is secondary, as cardiac complications are less immediate. Cool compresses and soft foods are less critical.