Nokea
The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the healthcare provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first?
- A. Gather the needed supplies for the procedure.
- B. Obtain a signed informed consent form.
- C. Assist the client into a side-lying position.
- D. Discuss the procedure with the client.
Correct Answer: B
Rationale: Informed consent (B) is required before invasive procedures, a priority. Gathering supplies (A), positioning (C), and discussion (D) follow.
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You're teaching a group of long-term care health givers about the signs and symptoms of tuberculosis. What signs and symptoms will you include in your education?
- A. Cough for a minimum of 6 weeks
- B. Night sweats
- C. Weight gain
- D. Hemoptysis
- E. Chills
- F. Fever
- G. Chest pain
Correct Answer: B,D,E,F,G
Rationale: Option A is wrong because a cough should be present for 3 weeks or more (NOT 6 weeks). Option C is wrong because the patient will experience weight LOSS (not gain).
Your patient with a diagnosis of latent tuberculosis infection needs a bronchoscopy. During transport to endoscopy, the patient will need to wear?
- A. N95 mask
- B. Surgical mask
- C. No special PPE is needed
- D. Face mask with shield
Correct Answer: C
Rationale: Patients with a latent tuberculosis infection are NOT contagious. Therefore, no special PPE is needed for the patient during transport. HOWEVER, if the patient had ACTIVE tuberculosis they would need to wear a surgical mask during transport.
Which assessment finding noted by the nurse on the client's return to the room is an early indication that the client's oxygenation status is compromised?
- A. The client's dressing is bloody.
- B. The client appears restless.
- C. The client's heart rate is irregular.
- D. The client indicates feeling cold.
Correct Answer: B
Rationale: Restlessness is an early sign of hypoxia, indicating compromised oxygenation status, which requires immediate attention.
A patient taking Isoniazid (INH) should be monitored for what deficiency?
- A. Vitamin C
- B. Calcium
- C. Vitamin B6
- D. Potassium
Correct Answer: C
Rationale: Isoniazid can cause peripheral neuropathy due to vitamin B6 (pyridoxine) deficiency. Patients are often given B6 supplements and monitored for this deficiency.
The nurse knows to discontinue the client's sponge bath if the client develops which symptom?
- A. Nausea
- B. Chills
- C. Flushing
- D. Confusion
Correct Answer: B
Rationale: Chills during a sponge bath indicate the client is becoming too cold, which can worsen discomfort and should prompt discontinuation.