Nokea
The nurse notes new onset confusion in an older-adult patient in a long-term care facility. The patient is normally alert and oriented. In which order should the nurse take the following actions?
- A. Obtain the oxygen saturation.
- B. Check the patient's pulse rate.
- C. Document the change in status.
- D. Notify the health care provider.
Correct Answer: A,B,D,C
Rationale: Assessment for physiological causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done.
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Which of the following information obtained by the nurse about a patient who has human immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to communicate to the health care provider?
- A. The Mantoux test had an induration of only 8 mm.
- B. The chest x-ray showed infiltrates in the upper lobes.
- C. The patient is being treated with antiretrovirals for HIV infection.
- D. The patient has a cough that is productive of blood-tinged mucus.
Correct Answer: C
Rationale: Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat tuberculosis. The other data are expected in a patient with HIV and TB disease.
Which of the following prescriptions should the nurse implement first for a patient who has just been admitted with probable bacterial pneumonia and sepsis?
- A. Administer Aspirin suppository.
- B. Send to radiology for chest x-ray.
- C. Give ciprofloxacin 400 mg IV.
- D. Obtain blood cultures from two sites.
Correct Answer: D
Rationale: Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and Aspirin administration can be done last.
To determine the effectiveness of prescribed therapies for a patient with cor pulmonale and right-sided heart failure, which of the following assessments should the nurse make?
- A. Lung sounds
- B. Heart sounds
- C. Blood pressure
- D. Peripheral edema
Correct Answer: D
Rationale: Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular vein distension, and right upper-quadrant abdominal tenderness would be expected. Abnormalities in lung sounds, blood pressure, or heart sounds are not caused by cor pulmonale.
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.
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.