Nokea
The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first?
- A. The 65-year-old client diagnosed with tuberculosis who has a sputum specimen to be sent to the laboratory.
- B. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged feeding tube.
- C. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%.
- D. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation level of 89%.
Correct Answer: D
Rationale: SpO2 89% (D) indicates significant hypoxia, requiring immediate assessment. TB sputum (A), clogged tube (B), and SpO2 92% (C) are less urgent.
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A 52-year old female patient is receiving medical treatment for a possible tuberculosis infection. The patient is a U.S. resident but grew-up in a foreign country. She reports that as a child she received the BCG vaccine (bacille Calmette-Guerin vaccine). Which physician's order below would require the nurse to ask the doctor for an order clarification?
- A. PPD (Mantoux test)
- B. Chest X-ray
- C. QuantiFERON-TB Gold (QFT)
- D. Sputum culture
Correct Answer: A
Rationale: Patients who have received the BCG vaccine will have a false positive on a PPD (Mantoux test), which is the tuberculin skin test. The BCG vaccine is a vaccine to prevent TB. It is given in foreign countries to children to prevent TB. Therefore, the person has already been exposed to the bacteria via vaccine and will have a false positive. A QuantiFERON-TB Gold test is a better option for this patient. It is a blood test.
A patient's D-dimer result is <500 ng/mL (FEU). The nurse knows that the D-dimer assesses and this result means?
- A. fibrin degradation fragment; positive for a blood clot
- B. platelet degradation protein; negative for a blood clot
- C. clotting factors; positive for a blood clot
- D. fibrin degradation fragment; negative for a blood clot
Correct Answer: D
Rationale: A d-dimer test assess fibrin degradation fragment. This test doesn't tell us where the clot may be (so it not specific) so it will need to be further investigated by the MD and a positive result doesn't necessarily mean the patient has a clot because some disease processes can cause a false positive. Also, a normal d-dimer is <500 ng/mL (FEU). However, it depends on how the lab reports the assay cut-off value for the d-dimer. Some labs have a cutoff <250 ng/mL (D-DU). However, <500 ng/mL (FEU) is equivalent to <250 ng/mL (D-DU).
A 48-year old homeless man, who is living in a local homeless shelter and is an IV drug user, has arrived to the clinic to have his PPD skin test assessed. What is considered a positive result?
- A. 5 mm induration
- B. 15 mm induration
- C. 9 mm induration
- D. 10 mm induration
Correct Answer: D
Rationale: 15 mm induration is positive in ALL people regardless of health history or risk factors. However, for patients who are homeless (living in homeless shelter) and are IV drug users, a 10 mm or more is considered positive.
Which statement indicates to the nurse the client diagnosed with asthma understands the teaching regarding mast cell stabilizer medications?
- A. I should take two (2) puffs when I begin to have an asthma attack.
- B. I must taper off the medications and not stop taking them abruptly.
- C. These drugs will be most effective if taken at bedtime.
- D. These drugs are not good at the time of an attack.
Correct Answer: D
Rationale: Mast cell stabilizers (D) prevent asthma by stabilizing mast cells, not treating acute attacks. Puffs during attack (A), tapering (B), and bedtime use (C) are incorrect.
Aside from the characteristics of the client's cough, which other pertinent assessment finding should the nurse document?
- A. Family history of respiratory disease
- B. Current vital signs
- C. Appearance of respiratory secretions
- D. Any self-treatment measures used by the client
Correct Answer: C
Rationale: The appearance of respiratory secretions (color, consistency) provides critical information about the infection's severity and type.