Nokea
The health care provider writes a prescription for bacteriological testing for a patient who has a positive tuberculosis skin test. Which of the following actions should the nurse take?
- A. Repeat the tuberculin skin testing.
- B. Teach about the reason for the blood tests.
- C. Obtain consecutive sputum specimens from the patient for 3 days.
- D. Instruct the patient to expectorate three specimens as soon as possible.
Correct Answer: C
Rationale: Three consecutive sputum specimens are obtained on different days for bacteriological testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. Once skin testing is positive, it is not repeated.
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A patient with newly diagnosed lung cancer tells the nurse, 'I think I am going to die pretty soon.' Which of the following responses by the nurse is best?
- A. Would you like to talk to the hospital chaplain about your feelings?
- B. Can you tell me what it is that makes you think you will die so soon?
- C. Are you afraid that the treatment for your cancer will not be effective?
- D. Do you think that taking an antidepressant medication would be helpful?
Correct Answer: B
Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning 'Can you tell me what it is' is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, 'Are you afraid' implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.
The nurse is assessing a patient who has just arrived after an automobile accident and the nurse notes that the breath sounds are absent on the right side. Which of the following actions should the nurse anticipate?
- A. Emergency pericardiocentesis
- B. Stabilization of the chest wall with tape
- C. Administration of an inhaled bronchodilator
- D. Insertion of a chest tube with a chest drainage system
Correct Answer: D
Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.
The nurse is conducting a chest assessment on a patient with pneumococcal pneumonia. Which of the following findings should the nurse expect to assess?
- A. Vesicular breath sounds
- B. Increased tactile fremitus
- C. Dry, nonproductive cough
- D. Hyper-resonance to percussion
Correct Answer: B
Rationale: Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical.
The nurse is caring for a patient who has just had a thoracentesis. Which of the following information is most important to communicate to the health care provider?
- A. BP is 150/90 mm Hg.
- B. Oxygen saturation is 89%.
- C. Pain level is 5/10 with a deep breath.
- D. Respiratory rate is 24 when lying flat.
Correct Answer: B
Rationale: Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.
The nurse is performing tuberculosis (TB) screening in a clinic that has many patients who have immigrated to Canada. Before doing a TB skin test on a patient, which of the following questions is most important for the nurse to ask?
- A. Is there any family history of TB?
- B. Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?
- C. How long have you lived in the Canada?
- D. Do you take any over-the-counter (OTC) medications?
Correct Answer: B
Rationale: Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.