Nokea
The employee health nurse is administering tuberculin skin testing to employees who have possibly been exposed to a client with active tuberculosis (Tb). Which statement indicates the need for radiological evaluation instead of skin testing?
- A. The client's first skin test indicates a purple flat area at the site of injection.
- B. The client's second skin test indicates a red area measuring four (4) mm.
- C. The client's previous skin test was read as positive.
- D. The client has never shown a reaction to the tuberculin medication.
Correct Answer: C
Rationale: A prior positive TB skin test (C) indicates exposure, requiring CXR to assess active disease, not repeat skin testing. Purple area (A) is normal, 4 mm (B) is negative, and no reaction (D) warrants testing.
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The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of 'impaired gas exchange.' Which is an expected outcome for this problem?
- A. Performs chest physiotherapy three (3) times a day.
- B. Able to complete activities of daily living.
- C. Ambulates in the hall several times during each shift.
- D. Alert and oriented to person, place, time, and events.
Correct Answer: D
Rationale: Alert/oriented status (D) indicates improved oxygenation from resolved gas exchange impairment. Physiotherapy (A) is an intervention, ADLs (B) and ambulation (C) are secondary outcomes.
You note your patient's sweat and urine is orange. You reassure the patient and educate him that which medication below is causing this finding?
- A. Ethambutol
- B. Streptomycin
- C. Isoniazid
- D. Rifampin
Correct Answer: D
Rationale: This medication will cause body fluids to turn orange.
Which is the best response from the nurse?
- A. Tell me more about how you are feeling.
- B. There are lots of things you can still do.
- C. You are just having a bad day today.
- D. What makes you say that?
Correct Answer: A
Rationale: Encouraging the client to express feelings fosters therapeutic communication and helps address emotional concerns related to COPD.
The charge nurse receives morning laboratory and respiratory data on the clients. Which data requires immediate intervention?
- A. ABG results of pH 7.35, Paco2 56, Hco3 29, Pao2 78 for a client diagnosed with COPD.
- B. Pulse oximetry reading of 89% on a two-day postsurgical total knee replacement client.
- C. Hgb of 9 g/dL and Hct of 28% on a client who is receiving the second unit of blood.
- D. B-type natriuretic peptide (BNP) of 100 on a client diagnosed with stage 4 congestive heart failure.
Correct Answer: B
Rationale: SpO2 89% post
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.