Nokea
The client admitted for recurrent aspiration pneumonia is at risk for bronchiectasis. Which intervention should the nurse anticipate the health-care provider to order?
- A. Administer intravenous antibiotics for seven (7) days.
- B. Insert a subclavian line and initiate total parenteral nutrition.
- C. Provide a low-calorie and low-sodium restricted diet.
- D. Encourage the client to turn, cough, and deep breathe frequently.
Correct Answer: D
Rationale: Recurrent aspiration pneumonia predisposes to bronchiectasis due to chronic airway damage. Turning, coughing, and deep breathing (D) prevent secretion stasis and further infections. Antibiotics (A) treat active infection, not prevention. TPN (B) is for malnutrition, not directly related. Dietary restrictions (C) are irrelevant.
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If the client identifies that lunches often include the following foods, which meal is the most nutritious?
- A. Tossed salad, rice, and iced tea
- B. Apple sandwich on whole wheat bread and coffee
- C. Meatless chili with beans, corn bread, and milk
- D. Chicken soup, gelatin, and sweetened lemonade
Correct Answer: C
Rationale: Meatless chili with beans, corn bread, and milk provides protein, carbohydrates, and calcium, making it the most balanced and nutritious option.
A patient receiving medical treatment for an active tuberculosis infection asks when she can starting going out in public again. You respond that she is no longer contagious when:
- A. She has 3 negative sputum cultures
- B. Her signs and symptoms improve
- C. She has completed the full medication regime
- D. Her chest x-ray is normal
- E. She has been on tuberculosis medications for about 3 weeks
Correct Answer: A
Rationale: A patient with active TB is considered non-contagious after three consecutive negative sputum cultures, indicating no viable bacteria. Symptom improvement, medication duration, or normal X-rays alone do not confirm non-contagiousness.
The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms should the nurse expect to assess in the client?
- A. Confusion and lethargy.
- B. High fever and chills.
- C. Frothy sputum and edema.
- D. Bradypnea and jugular vein distention.
Correct Answer: A
Rationale: Elderly pneumonia patients often present with confusion/lethargy (A) due to hypoxia. Fever/chills (B) are less common in the elderly, frothy sputum/edema (C) suggest heart failure, and bradypnea/JVD (D) are unrelated.
The nurse observes the client sitting on the side of the bed with the arms propped on the over-bed table. The chest is barrel shaped and the client is breathing though lips spaced close together and is exhaling slowly. Which concept is priority for this client?
- A. Mobility.
- B. Nutrition.
- C. Activity intolerance.
- D. Oxygenation.
Correct Answer: D
Rationale: Tripod position, barrel chest, and pursed-lip breathing (D) indicate COPD with oxygenation as the priority. Mobility (A), nutrition (B), and activity (C) are secondary.
Your patient, who is receiving Pyrazinamide, report stiffness and extreme pain in the right big toe. The site is extremely red, swollen, and warm. You notify the physician and as the nurse you anticipated the doctor will order?
- A. Calcium level
- B. Vitamin B6 level
- C. Uric acid level
- D. Amylase level
Correct Answer: C
Rationale: This medication can increase uric acid levels which can lead to gout. The patient's signs and symptoms are classic findings in a gout attack.