Nokea
As the nurse you know that one of the reasons for an increase in multidrug-resistant tuberculosis is:
- A. Incorrect medication ordered
- B. Increase in tuberculosis cases nationwide
- C. Incorrect route of drug ordered
- D. Noncompliance due to duration of medication treatment needed
Correct Answer: D
Rationale: Patients must be on medication treatment for about 6-12 months (depending on the type of TB the patient has). This leads to noncompliant issues. DOT (directly observed therapy) is now being instituted so compliance is increased. This is where a public health nurse or a trained DOT worker will deliver the medication and watch the patient swallow the pill until treatment is complete.
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The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement?
- A. Administer oral anticoagulants.
- B. Assess the client's bowel sounds.
- C. Prepare the client for a thoracentesis.
- D. Institute and maintain bedrest.
Correct Answer: D
Rationale: Bedrest (D) reduces oxygen demand and embolism risk in PE. Oral anticoagulants (A) follow heparin, bowel sounds (B) are unrelated, and thoracentesis (C) is for pleural effusion.
Which statement best suggests that the client understands the nurse's instruction on how to handle the sputum specimen container?
- A. I should wipe the container with an alcohol swab.
- B. I must not touch the inside of the container.
- C. I cannot put the lid on the container until the container is fairly full.
Correct Answer: B
Rationale: Not touching the inside of the container prevents contamination, ensuring an accurate sputum sample.
Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator?
- A. The client's urine output is 100 mL in four (4) hours.
- B. The pulse oximeter reading is greater than 95%.
- C. The client has asymmetrical chest expansion.
- D. The telemetry reading shows sinus tachycardia.
Correct Answer: C
Rationale: Asymmetrical chest expansion (C) suggests pneumothorax, a ventilator complication. Low urine (A), SpO2 >95% (B), and tachycardia (D) are unrelated or expected.
The client is admitted to the emergency department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax?
- A. Bronchovesicular lung sounds and bradypnea.
- B. Unequal lung expansion and dyspnea.
- C. Frothy, bloody sputum and consolidation.
- D. Barrel chest and polycythemia.
Correct Answer: B
Rationale: Pneumothorax causes unequal lung expansion and dyspnea (B) from collapsed lung. Bronchovesicular sounds/bradypnea (A), frothy sputum (C), and barrel chest (D) suggest other conditions.
The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms should the nurse assess in the client?
- A. Pleuritic chest discomfort and anxiety.
- B. Asymmetrical chest expansion and pallor.
- C. Leukopenia and CRT <three (3) seconds.
- D. Substernal chest pain and diaphoresis.
Correct Answer: A
Rationale: Pneumonia causes pleuritic chest pain and anxiety (A) from inflammation/hypoxia. Asymmetry (B) suggests pneumothorax, leukopenia (C) is atypical, and substernal pain (D) suggests MI.