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The nurse is caring for a patient who has a right-sided chest tube following a thoracotomy and has continuous bubbling in the suction-control chamber of the collection device. Which of the following actions should the nurse implement?
- A. Document the presence of a large air leak.
- B. Obtain and attach a new collection device.
- C. Notify the surgeon of a possible pneumothorax.
- D. Take no further action with the collection device.
Correct Answer: D
Rationale: Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled.
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The nurse is caring for a patient who is hospitalized with active tuberculosis (TB) and the nurse observes a family member who is visiting the patient. Which of the following actions by the visitor should cause the nurse to intervene?
- A. Washes hands before entering the patient's room
- B. Hands the patient a tissue from the box at the bedside
- C. Puts on a surgical face mask before visiting the patient
- D. Brings food from a 'fast-food' restaurant to the patient
Correct Answer: C
Rationale: An N95 mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Handwashing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.
Which of the following information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions?
- A. Chest x-ray shows no upper lobe infiltrates.
- B. TB medications have been taken for 6 months.
- C. Mantoux testing shows an induration of 10 mm.
- D. Three sputum smears for acid-fast bacilli are negative.
Correct Answer: D
Rationale: Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done since it will not change even with effective treatment.
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 with pneumonia who has symptoms of a sharp pain 'whenever I take a deep breath.' Which of the following actions should the nurse take next?
- A. Listen to the patient's lungs.
- B. Administer the PRN morphine.
- C. Have the patient cough forcefully.
- D. Notify the patient's health care provider.
Correct Answer: A
Rationale: The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.
The nurse is teaching a patient who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications. Which of the following findings should the nurse instruct the patient to report to the health care provider?
- A. Yellow-tinged skin
- B. Changes in hearing
- C. Orange-coloured sputum
- D. Thickening of the fingernails
Correct Answer: A
Rationale: Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Orange discoloration of body fluids is an expected adverse effect of rifampin and not an indication to call the health care provider.