Nokea
The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement?
- A. Assess respiratory rate and depth.
- B. Provide for adequate rest period.
- C. Administer oxygen as prescribed.
- D. Teach slow abdominal breathing.
Correct Answer: C
Rationale: Administering oxygen as prescribed (C) is the priority for bacterial pneumonia to address hypoxemia, a common issue due to impaired gas exchange. Assessing respiratory rate (A) is important but secondary to ensuring oxygenation. Rest (B) and breathing techniques (D) support recovery but are not the first priority.
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You are assessing your newly admitted patients who are all presenting with atypical signs and symptoms of a possible lung infection. The physician suspects tuberculosis. So, therefore, the patients are being monitored and tested for the disease. Select all the risk factors below that increases a patient's risk for developing tuberculosis:
- A. Diabetes
- B. Liver failure
- C. Long-term care resident
- D. Inmate
- E. IV drug user
- F. HIV
- G. U.S. resident
Correct Answer: A,C,D,E,F
Rationale: Risk factors for tuberculosis include conditions or environments that weaken the immune system or increase exposure: diabetes , long-term care residency , incarceration , IV drug use , and HIV . Liver failure is not a direct risk factor, and being a U.S. resident is not specific enough.
The 56-year-old client diagnosed with tuberculosis (Tb) is being discharged. Which statement made by the client indicates an understanding of the discharge instructions?
- A. I will take my medication for the full three (3) weeks prescribed.
- B. I must stay on the medication for months if I am to get well.
- C. I can be around my friends because I have started taking antibiotics.
- D. I should get a Tb skin test every three (3) months to determine if I am well.
Correct Answer: B
Rationale: TB treatment requires months of antibiotics (B) for cure. Three weeks (A) is too short, antibiotics don’t eliminate transmission risk immediately (C), and skin tests (D) monitor exposure, not cure.
The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the licensed practical nurse (LPN)?
- A. The client with pneumonia who has a pulse oximeter reading of 91%.
- B. The client with a hemothorax who has Hb of 9 g/dL and Hct of 20%.
- C. The client with chest tubes who has jugular vein distention and BP of 96/60.
- D. The client who is two (2) hours post-bronchoscopy procedure.
Correct Answer: D
Rationale: Post-bronchoscopy (D) is stable for LPN care. Hypoxia (A), anemia (B), and JVD/hypotension (C) require RN assessment.
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.
The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms should the nurse expect to assess in the client?
- A. Confusion and lethargy.
- B. High fever and chills.
- C. Frothy sputum and edema.
- D. Bradypnea and jugular vein distention.
Correct Answer: A
Rationale: Elderly pneumonia patients often present with confusion/lethargy (A) due to hypoxia. Fever/chills (B) are less common in the elderly, frothy sputum/edema (C) suggest heart failure, and bradypnea/JVD (D) are unrelated.