Nokea
The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client?
- A. A red area is a positive reading that means the client has tuberculosis.
- B. The skin test is the only procedure needed to diagnose tuberculosis.
- C. A positive reading means exposure to the tuberculosis bacilli.
- D. Do not get another skin test for one (1) year if the skin test is positive.
Correct Answer: C
Rationale: A positive TB skin test (C) indicates exposure to TB bacilli, not active disease, requiring further testing (e.g., chest X-ray). Redness alone (A) is not diagnostic; induration is measured. The skin test (B) is not definitive for diagnosis. Annual testing (D) may be needed in high-risk groups.
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Which statement made by the client indicates the nurse's discharge teaching is effective for the client diagnosed with COPD?
- A. I need to get an influenza vaccine each year, even when there is a shortage.
- B. I need to get a vaccine for pneumonia each year with my influenza shot.
- C. If I reduce my cigarettes to six (6) a day, I won't have difficulty breathing.
- D. I need to restrict my drinking liquids to keep from having so much phlegm.
Correct Answer: A
Rationale: Annual flu vaccines (A) reduce COPD exacerbation risk, even in shortages. Pneumonia vaccines (B) are not yearly, smoking reduction (C) is insufficient, and fluid restriction (D) is incorrect.
Select all the medications used to treat pneumonia that are narrowspectrum?
- A. Macrolides
- B. Tamiflu
- C. Fluroquinolones
- D. Penicillins
Correct Answer: A,D
Rationale: Narrow-spectrum antibiotics target specific bacteria. Macrolides and Penicillins are narrow-spectrum, effective against gram-positive bacteria common in pneumonia. Tamiflu is antiviral, and Fluoroquinolones are broad-spectrum.
When suctioning a client with a tracheostomy, when is the best time to occlude the vent on the suction catheter?
- A. Before inserting the catheter
- B. When inside the inner cannula
- C. While withdrawing the catheter
- D. When the client begins coughing
Correct Answer: C
Rationale: Occluding the vent while withdrawing the catheter applies suction to remove secretions effectively.
An adult with tuberculosis has started taking rifampin (Rimactane). Which side effect is the client most likely to experience when taking this drug?
- A. Reddish-orange color of urine, sputum, and saliva
- B. Erythema and urticaria
- C. Tinnitus and deafness
- D. Peripheral neuritis
Correct Answer: A
Rationale: Rifampin commonly causes a harmless reddish-orange discoloration of body fluids.
The client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the medical unit. The client has thin extremities, truncal obesity, and multiple ecchymotic areas on the arms. Based on the assessment data, which question should the nurse ask the client?
- A. Do you take prednisone?
- B. Can you tell me who hurts you?
- C. May I check your coccyx for pressure areas?
- D. Do you sleep with the head of the bed elevated?
Correct Answer: A
Rationale: Thin limbs, truncal obesity, and ecchymosis (A) suggest corticosteroid use (e.g., prednisone) in COPD. Abuse (B), pressure ulcers (C), and HOB elevation (D) are less likely.