Nokea
The client who smokes two (2) packs of cigarettes a day develops ARDS after a near-drowning. The client asks the nurse, 'What is happening to me? Why did I get this?' Which statement by the nurse is most appropriate?
- A. Most people who almost drown end up developing ARDS.
- B. Platelets and fluid enter the alveoli due to permeability instability.
- C. Your lungs are filling up with fluid, causing breathing problems.
- D. Smoking has caused your lungs to become weakened, so you got ARDS.
Correct Answer: C
Rationale: Fluid-filled lungs (C) explain ARDS simply, addressing breathing issues. Drowning link (A), permeability (B), and smoking (D) are less accurate or overly technical.
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You are assessing your newly admitted patients who are all presenting with atypical signs and symptoms of a possible lung infection. The physician suspects tuberculosis. So, therefore, the patients are being monitored and tested for the disease. Select all the risk factors below that increases a patient's risk for developing tuberculosis:
- A. Diabetes
- B. Liver failure
- C. Long-term care resident
- D. Inmate
- E. IV drug user
- F. HIV
- G. U.S. resident
Correct Answer: C,D,E,F
Rationale: Remember from our lecture we discussed the risk factors for developing TB and to remember them I said remember the mnemonic "TB Risk". It stands for tight living quarters (LTC resident, prison, homeless shelter etc.), below or at the poverty line (homeless), refugee (especially in high risk countries), immune system issue such as HIV, substance abusers (IV drugs or alcohol), Kids less than the age of 5....all these are risk factors.
To evaluate the significance of the client's bleeding, which additional assessment is most important for the nurse to make at this time?
- A. Count the pulse rate.
- B. Listen to heart sounds.
- C. Check the pupillary response.
- D. Measure the chest expansion.
Correct Answer: D
Rationale: Measuring chest expansion helps assess for complications like pneumothorax, which could cause bleeding post-bronchoscopy.
A patient is receiving continuous IV Heparin for anticoagulation therapy for the treatment of a DVT. In order for this medication to have a therapeutic effect on the patient, the aPTT should be?
- A. 0.5-2.5 times the normal value range
- B. 2-3 times the normal value range
- C. 1.5-2.5 times the normal value range
- D. 1-3.5 times the normal value range
Correct Answer: C
Rationale: An aPTT should be 1.5-2.5 times the normal value range for Heparin to achieve a therapeutic effect in a patient to prevent blood clots. If the aPTT is too low, blood clots can form. If the aPTT is too high, bleeding can occur.
Which of the following patients are MOST at risk for developing pneumonia? Select-all-that-apply:
- A. A 53 year old female recovering from abdominal surgery.
- B. A 69 year old patient who recently received the pneumococcal conjugate vaccine.
- C. A 42 year old male with COPD and is on continuous oxygen via nasal cannula.
- D. A 8 month old with RSV (respiratory syncytial virus) infection.
Correct Answer: A,C,D
Rationale: Patients recovering from surgery are at risk due to immobility and impaired cough reflex, those with COPD have chronic lung disease increasing susceptibility, and infants with RSV are prone to secondary bacterial pneumonia. The vaccinated patient has reduced risk due to immunity.
The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client?
- A. A red area is a positive reading that means the client has tuberculosis.
- B. The skin test is the only procedure needed to diagnose tuberculosis.
- C. A positive reading means exposure to the tuberculosis bacilli.
- D. Do not get another skin test for one (1) year if the skin test is positive.
Correct Answer: C
Rationale: A positive TB skin test (C) indicates exposure to TB bacilli, not active disease, requiring further testing (e.g., chest X-ray). Redness alone (A) is not diagnostic; induration is measured. The skin test (B) is not definitive for diagnosis. Annual testing (D) may be needed in high-risk groups.