Nokea
How long after administering a tuberculin skin test should the nurse inspect the client's injection site?
- A. 1 week
- B. 1 day
- C. 2 to 3 days
- D. 4 to 5 days
Correct Answer: C
Rationale: The tuberculin skin test reaction is typically read 48 to 72 hours (2 to 3 days) after administration to assess for induration.
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When caring for a client with a flail chest, which nursing action is most appropriate?
- A. Suction the client's airway.
- B. Tape the chest securely.
- C. Apply a chest binder.
- D. Encourage coughing.
Correct Answer: C
Rationale: Applying a chest binder stabilizes the flail chest, reducing paradoxical chest movement and improving ventilation.
A patient, who is receiving continuous IV Heparin for the treatment of a DVT, has an aPTT of 110 seconds. What is your next nursing action per protocol?
- A. Continue with the infusion because no change is needed based on this aPTT.
- B. Increase the drip rate per protocol because the aPTT is too low.
- C. Re-draw the aPTT STAT.
- D. Hold the infusion for 1 hour and decrease the rate per protocol because the aPTT is too high.
Correct Answer: D
Rationale: The aPTT is 110 seconds, which is too high. Any aPTT value greater than 80 seconds places the patient at risk for bleeding. Most Heparin protocols dictate that the nurse would hold the infusion for 1 hour and to decrease the rate of infusion. If the aPTT is less than 60 seconds, the dose would need to be increased and a bolus may be needed. aPTT values should be around 60-80 seconds to achieve a therapeutic response for Heparin.
A 55-year old male patient is admitted with an active tuberculosis infection. The nurse will place the patient in precautions and will always wear when providing patient care?
- A. droplet, respirator
- B. airborne, respirator
- C. contact and airborne, surgical mask
- D. droplet, surgical mask
Correct Answer: B
Rationale: A patient with ACTIVE TB is contagious. The bacterium, mycobacterium tuberculosis which causes TB, is so small that it can stay suspended in the air for hours to days. Therefore, the nurse will place the patient in AIRBORNE precautions. In addition, a special mask must be worn called a respirator (as referred to as an N95 mask.....a surgical mask does NOT work with this condition).
The nurse is admitting a client with a diagnosis of rule-out cancer of the larynx. Which information should the nurse teach?
- A. Demonstrate the proper method of gargling with normal saline.
- B. Perform voice exercises for 30 minutes three (3) times a day.
- C. Explain that a lighted instrument will be placed in the throat to biopsy the area.
- D. Teach the client to self-examine the larynx monthly.
Correct Answer: C
Rationale: Laryngoscopy with biopsy (C) diagnoses laryngeal cancer, requiring client education. Gargling (A), voice exercises (B), and self-examination (D) are not diagnostic.
The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client?
- A. Daily inhaled corticosteroids.
- B. Use of a 'rescue inhaler.'
- C. Use of systemic steroids.
- D. Leukotriene agonists.
Correct Answer: B
Rationale: Mild intermittent asthma requires a rescue inhaler (B) (e.g., albuterol) for PRN use. Daily corticosteroids (A), systemic steroids (C), and leukotrienes (D) are for persistent asthma.