Nokea
The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?
- A. Hepatitis testing
- B. Tuberculosis screening
- C. Contraceptive teaching
- D. Colonoscopy information
Correct Answer: B
Rationale: Tuberculosis (TB) is prevalent in many parts of Asia, including Vietnam, and the incidence of TB is higher in immigrants from Vietnam compared to the general U.S. population. Conducting tuberculosis screening is crucial to identify and address any cases promptly, especially in a community with recent immigrants from Vietnam. While teaching about contraceptive use, providing colonoscopy information, and testing for hepatitis may be relevant for certain individuals in the community, they are not as universally important as tuberculosis screening due to the increased risk of TB among Vietnamese immigrants.
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When auscultating the patient's lungs during a shift assessment on a patient admitted in the early phase of heart failure, which finding would the nurse most likely hear?
- A. Continuous rumbling, snoring, or rattling sounds mainly on expiration
- B. Continuous high-pitched musical sounds on inspiration and expiration
- C. Discontinuous, high-pitched sounds of short duration heard on inspiration
- D. A series of long-duration, discontinuous, low-pitched sounds during inspiration
Correct Answer: C
Rationale: In the early phase of heart failure, fine crackles are likely to be heard upon auscultation of the lungs. Fine crackles are characterized as discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration, which are often associated with airway secretions. Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration, typically indicating fluid in the alveoli. Wheezes are continuous high-pitched musical sounds on inspiration and expiration, commonly heard in conditions like asthma or chronic obstructive pulmonary disease (COPD). Therefore, the correct choice is C, as it describes the expected lung sounds in a patient with early heart failure.
When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action?
- A. Weak cough effort
- B. Barrel-shaped chest
- C. Dry mucous membranes
- D. Bilateral crackles at lung bases
Correct Answer: D
Rationale: Bilateral crackles at lung bases indicate a potential acute issue like heart failure. Immediate action is necessary in this situation. The nurse should conduct further assessments such as oxygen saturation and inform the healthcare provider promptly. A barrel-shaped chest and hyperresonance to percussion are typical signs of aging and do not require immediate action. A weak cough effort is common in older patients due to age-related changes, and dry mucous membranes are also expected in older individuals. While these findings may warrant further evaluation, they do not demand immediate action like bilateral crackles at lung bases.
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
- A. Emergency pericardiocentesis
- B. Stabilization of the chest wall with tape
- C. Administration of an inhaled bronchodilator
- D. Insertion of a chest tube with a chest drainage system
Correct Answer: D
Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. Emergency pericardiocentesis is not indicated as the patient's symptoms are not suggestive of cardiac tamponade. Stabilization of the chest wall with tape would not address the underlying issue of a potential pneumothorax or hemothorax. Administration of an inhaled bronchodilator is not appropriate in this scenario as the patient is not exhibiting signs of asthma or bronchoconstriction. Therefore, the correct intervention for this patient is the insertion of a chest tube with a chest drainage system to address the potential pneumothorax or hemothorax.
The nurse caring for Mrs. J is prepared to suction her endotracheal tube. Which of the following interventions will reduce hypoxia during this procedure?
- A. Hyperoxygenate Mrs. J for up to 60 seconds prior to starting
- B. Administer 15 mL of sterile fluid into the tube prior to suctioning
- C. Suction for no longer than 30 seconds at a time
- D. Wait 30 seconds after suctioning before attempting again
Correct Answer: A
Rationale: Before suctioning a client's endotracheal tube, it is essential to hyperoxygenate the client for approximately 30 to 60 seconds. Hyperoxygenation helps increase oxygen delivery to the tissues, reducing the risk of hypoxia during and after the suctioning procedure. Administering fluid into the tube before suctioning (Choice B) is unnecessary and can lead to complications. Suctioning for no longer than 30 seconds at a time (Choice C) is a general guideline but does not specifically address reducing hypoxia. Waiting 30 seconds after suctioning before attempting again (Choice D) may lead to inadequate oxygenation and potential hypoxia, making it less effective in preventing this complication compared to hyperoxygenation prior to suctioning.
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?
- A. Is there any family history of TB?
- B. How long have you lived in the United States?
- C. Do you take any over-the-counter (OTC) medications?
- D. Have you received the bacille Calmette-Guerin (BCG) vaccine for TB?
Correct Answer: D
Rationale: It is crucial for the nurse to inquire about whether the patient has received the bacille Calmette-Guerin (BCG) vaccine for TB before performing the skin test. Patients who have received the BCG vaccine can have a positive Mantoux test, leading to the need for alternative screening methods, such as a chest x-ray, to determine TB infection. While family history of TB and length of time in the United States are relevant factors, they do not directly impact the decision to perform the TB skin test. Asking about over-the-counter medications, unless relevant to TB treatment, is not as critical as assessing BCG vaccination status.