Nokea
The home health nurse is making an initial call on a newly diagnosed tuberculosis (TB) patient. The patient lives with his wife and child. Which infection control instructions shouldn't the nurse include in the teaching plan?
- A. Place contaminated tissues in sealable plastic bag.
- B. Take medications exactly as directed.
- C. Implement airborne precautions.
- D. Wash hands frequently.
Correct Answer: C
Rationale: The correct answer is C because TB is transmitted through droplet transmission, not airborne. The nurse should include hand hygiene (D) to prevent spread through contact, proper medication adherence (B) to treat TB effectively, and proper disposal of contaminated materials (A) to prevent spread through fomites. Implementing airborne precautions is not necessary for TB, as it does not remain suspended in the air for long periods.
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A client has a tracheostomy tube in place. When the nurse suctions the client food particles are noted. What action by the nurse is best?
- A. Elevate the head of the client's bed.
- B. Measure and compare cuff pressures.
- C. Place the client on NPO status.
- D. Request that the client have a swallow study.
Correct Answer: B
Rationale: The correct answer is B: Measure and compare cuff pressures. When food particles are noted during suctioning, it indicates a potential issue with the tracheostomy tube cuff. By measuring and comparing cuff pressures, the nurse can ensure the cuff is properly inflated to prevent aspiration of food particles into the lungs. Elevating the head of the bed (choice A) is a standard practice for preventing aspiration but does not address the specific issue of cuff pressure. Placing the client on NPO status (choice C) is not necessary if the cuff pressure is the main concern. Requesting a swallow study (choice D) may be needed eventually but is not the immediate priority when food particles are already present.
If his R = 0.8 how much will his arterial pO2 fall?
- A. 85mmHg
- B. 75mmHg
- C. 60mmHg
- D. 50mmHg
Correct Answer: D
Rationale: The correct answer is D (50mmHg). To calculate the fall in arterial pO2, we use the formula: Fall in pO2 = (Initial pO2) - (Initial pO2 x R). If R = 0.8, the fall in pO2 = (100mmHg) - (100mmHg x 0.8) = 100mmHg - 80mmHg = 20mmHg. Therefore, the arterial pO2 will fall by 20mmHg. Among the choices, D (50mmHg) is the closest to the calculated value of 20mmHg, making it the correct answer. Other choices (A, B, C) do not align with the calculated fall in pO2.
A patient with active TB continues to have positive sputum cultures after 6 months of treatment. She says she cannot remember to take the medication all the time. What is the best action for the nurse to take?
- A. Schedule the patient to come to the clinic every day to take the medication.
- B. Have a patient who has recovered from TB tell the patient about his successful treatment.
- C. Schedule more teaching sessions so the patient will understand the risks of noncompliance.
- D. Arrange for directly observed therapy by a responsible family member or a public health nurse.
Correct Answer: D
Rationale: Directly observed therapy by a responsible family member or a public health nurse is the best action to ensure adherence to TB treatment and prevent further drug resistance.
The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis?
- A. Their location over a specific area of the lung
- B. The volume of the sounds
- C. Whether they are heard on inspiration or expiration
- D. Whether or not they are continuous breath sounds
Correct Answer: A
Rationale: The correct answer is A because vesicular, bronchovesicular, and bronchial breath sounds are distinguished based on their location over specific areas of the lung. Vesicular sounds are soft and low-pitched and are heard over most of the lung fields, bronchovesicular sounds are intermediate in pitch and are heard over the major bronchi, and bronchial sounds are loud and high-pitched and are heard over the trachea and larynx. Choices B, C, and D are incorrect as the distinction between these breath sounds is not based on volume, inspiration or expiration, or continuity of the sounds.
In teaching a patient with hypertension about controlling the illness the nurse recognizes that?
- A. All patients with elevated BP need drug therapy.
- B. Obese persons must achieve a normal weight to lower BP.
- C. It is not necessary to limit salt in the diet if taking a diuretic.
- D. Lifestyle modifications are needed for all persons with elevated BP.
Correct Answer: D
Rationale: Rationale:
D is correct because lifestyle modifications, such as exercise and diet changes, are essential for managing hypertension. This approach can help lower blood pressure without the need for drug therapy. A is incorrect because not all patients with elevated BP require medication. B is incorrect as weight loss is beneficial but not the only factor in controlling BP. C is incorrect because limiting salt intake remains important even if taking a diuretic.