Nokea
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?
- A. Bronchoscopy
- B. Chest X-ray
- C. TB skin test (Mantoux test)
- D. Sputum culture for acid-fast bacillus
Correct Answer: D
Rationale: The correct answer is D: Sputum culture for acid-fast bacillus. This test is the most reliable for confirming active pulmonary TB because it directly detects the presence of the Mycobacterium tuberculosis bacteria in the sputum sample. Bronchoscopy (A) may help visualize the airways but does not definitively confirm TB. Chest X-ray (B) can show characteristic findings suggestive of TB but cannot confirm the diagnosis. TB skin test (C) indicates exposure but not active disease. Sputum culture is the gold standard for diagnosing TB, as it allows for definitive identification of the bacteria.
You may also like to solve these questions
A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?
- A. Increase calcium intake
- B. Avoid foods high in potassium
- C. Drink 3 L of fluid every day
- D. Limit vitamin C intake
Correct Answer: C
Rationale: The correct answer is C: Drink 3 L of fluid every day. Adequate fluid intake helps to dilute urine, reducing the concentration of calcium and oxalate, which are the main components of kidney stones. This instruction can help prevent the formation of new stones. Increasing calcium intake (Choice A) may actually be beneficial as it can bind with oxalate in the intestines, reducing its absorption and subsequent excretion in the urine. Avoiding foods high in potassium (Choice B) is not directly related to preventing calcium oxalate stones. Limiting vitamin C intake (Choice D) is not necessary unless the client is taking excessive amounts of vitamin C supplements, which can increase oxalate levels.
A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?
- A. Electrocardiogram
- B. Chest X-ray
- C. Echocardiogram
- D. MRI of the chest
Correct Answer: D
Rationale: The correct answer is D. MRI of the chest should be clarified because the magnetic field can interfere with the function of the pacemaker, potentially causing harm to the patient. An electrocardiogram, chest X-ray, and echocardiogram are safe imaging tests that do not interfere with the pacemaker. Therefore, D is the correct answer that should be clarified to ensure patient safety.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. Serum albumin level
- B. WBC count
- C. Serum potassium level
- D. BUN
Correct Answer: B
Rationale: The correct answer is B: WBC count. An elevation in WBC count indicates an immune response to infection, as white blood cells increase to fight off pathogens. In the context of a pressure ulcer, an elevated WBC count suggests the presence of infection due to the body's response to foreign organisms. Other choices are not directly related to infection in this scenario. Serum albumin level (A) reflects nutritional status, serum potassium level (C) indicates electrolyte balance, and BUN (D) reflects kidney function. Hence, they are not specific indicators of infection in a client with a pressure ulcer.
A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?
- A. Limit the number of health care workers entering the room.
- B. Encourage the client to engage in social activities.
- C. Ensure the client receives a flu vaccine during chemotherapy.
- D. Provide daily fresh fruits and vegetables.
Correct Answer: A
Rationale: The correct answer is A: Limit the number of health care workers entering the room. This is important because immunosuppressed clients are at higher risk for infections. By limiting the number of health care workers entering the room, the nurse can reduce the client's exposure to potential pathogens. This helps to maintain a clean and controlled environment for the client, decreasing the risk of acquiring infections.
Choice B is incorrect because social activities may expose the client to a higher risk of infections from others. Choice C is incorrect because administering a flu vaccine during chemotherapy may not be effective due to the client's compromised immune system. Choice D is incorrect as providing fresh fruits and vegetables does not directly address the risk of infections from health care workers.
A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client?
- A. Good
- B. Excellent
- C. Fair
- D. Poor
Correct Answer: D
Rationale: The correct answer is D: Poor. In stage IV ovarian cancer, the cancer has spread beyond the ovaries to distant organs. Prognosis is generally poor due to the advanced stage of the disease. Aggressive treatments can help manage symptoms and improve quality of life but are unlikely to cure the cancer. Discussing a poor prognosis with the client allows for realistic expectations and informed decision-making. Choices A, B, and C are incorrect as they suggest a better prognosis which is not typical for stage IV ovarian cancer.