Nokea
Mr. and Mrs. Smith took part in a community health screening. What does a positive reaction to the standard intermediate strength PPD mean?
- A. Have active tuberculosis
- B. Are “carriers” of tuberculosis
- C. Have already transmitted tuberculosis to their children
- D. Have been exposed to active tuberculosis
Correct Answer: D
Rationale: A positive PPD test indicates past exposure to Mycobacterium tuberculosis but does not confirm active disease.
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A client with tuberculosis is starting combination drug therapy. Which of the following medications should the nurse NOT plan to administer?
- A. Rifampin
- B. Isoniazid
- C. Acyclovir
- D. Pyrazinamide
Correct Answer: C
Rationale: The correct answer is C: Acyclovir. Acyclovir is an antiviral medication used to treat herpes infections, not tuberculosis. Rifampin, Isoniazid, and Pyrazinamide are all first-line drugs for tuberculosis treatment. Rifampin is a bactericidal agent, Isoniazid disrupts mycobacterial cell wall synthesis, and Pyrazinamide targets actively replicating bacteria. Therefore, the nurse should not plan to administer Acyclovir as it is not indicated for tuberculosis treatment.
How should the nurse respond when asked his or her opinion about treatment decisions by the client or their family?
- A. Provide evidence-based recommendations while respecting autonomy.
- B. Defer all decisions to the physician.
- C. Share personal opinions openly.
- D. Avoid giving any opinion.
Correct Answer: A
Rationale: Providing evidence-based recommendations while respecting the client's autonomy ensures informed decision-making and maintains professionalism.
Which of the following is a definitive sign of pregnancy?
- A. Amenorrhea
- B. Positive hCG
- C. Morning sickness
- D. Fetal heart sounds
Correct Answer: D
Rationale: Fetal heart sounds are a definitive sign of pregnancy, confirming the presence of a viable fetus.
A client is experiencing episodes of hyperventilation related to the surgery scheduled for tomorrow. The appropriate nursing action to help control hyperventilation is to:
- A. administer Valium 10-15 mg PO q4h and q1h prn.
- B. keep the temperature in the client's room high to reduce respiratory stimulation.
- C. have the client hold their breath or breathe into a paper bag when the hyperventilation episodes occur.
- D. use distractions.
Correct Answer: C
Rationale: An adult Valium dosage for treatment of anxiety is 2-10 mg PO from two to four times daily. As written, the order would place a client at risk for an overdose. A high room temperature could increase the hyperventilating episodes by stimulating the respiratory system. Holding one's breath and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. Distraction will not prevent or control hyperventilation, which is caused by anxiety or fear.
Place the following interventions in the correct order.
- A. Apply a loose, sterile, bulky dressing
- B. Give pain medication
- C. Remove the victim from the cold environment
- D. Immerse the feet in warm water 100°F to 105°F (40.6°C to 46.1°C)
Correct Answer: C
Rationale: The first priority is removing the victim from the cold environment to prevent further damage.