Nokea
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.
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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.
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 caring for a patient who has a steering wheel injury as a result of an automobile accident. Which of the following findings should be of most concern to the nurse during the initial assessment?
- A. Paradoxical chest movement
- B. The complaint of chest wall pain
- C. A heart rate of 110 beats/minute
- D. A large bruised area on the chest
Correct Answer: A
Rationale: Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.
The nurse is caring for a patient with pneumonia has a fever of 38.4 C (101.1 F). Which of the following orders should the nurse implement first?
- A. Administer acetaminophen 650 mg.
- B. Obtain blood and sputum cultures.
- C. Administer ceftriaxone 1 g IV.
- D. Give patient cool compresses.
Correct Answer: B
Rationale: Obtaining cultures before antibiotic administration is critical to identify the causative organism and ensure appropriate treatment. Administering acetaminophen and ceftriaxone are important but should follow culture collection to avoid altering results. Cool compresses are a supportive measure but not the priority.
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.