Nokea
The nurse reading a tuberculin skin test (TST) on a new employee who lives in the Midwest,
is 20-years-old, and has no known history of contact with any people with tuberculosis (TB).
The nurse should interpret the reading as positive if the area around the injection site has an
induration of how many millimeters?
- A. 0 mm
- B. 5 mm
- C. 10 mm
- D. 15 mm
Correct Answer: D
Rationale: The correct answer is D (15 mm) because for a low-risk individual like the new employee, a TST is considered positive if the induration is 15 mm or greater. This is based on the guidelines from the Centers for Disease Control and Prevention (CDC) for interpreting TST results in individuals without known risk factors. Choices A, B, and C are incorrect because an induration of 0 mm, 5 mm, or 10 mm, respectively, would not meet the criteria for a positive TST in this low-risk individual. It is important to consider the individual's risk factors and follow established guidelines to accurately interpret TST results.
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A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform first?
- A. Facial pain
- B. Vital signs
- C. Bone displacement
- D. Airway patency
Correct Answer: D
Rationale: The correct answer is D: Airway patency. Ensuring airway patency is the top priority in any client assessment, especially in cases of facial trauma like a nasal fracture. This is because compromised airway can lead to respiratory distress or failure. Assessing airway patency should always be the first step to ensure the client's ability to breathe.
Facial pain (A) may be important but does not address immediate life-threatening concerns. Vital signs (B) are important but assessing airway patency takes precedence for client safety. Bone displacement (C) is relevant but does not address the immediate need to maintain airway patency.
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure?
- A. Measure oxygen saturation before and after a 12-minute walk.
- B. Verify that the client understands all possible complications.
- C. Explain the procedure in detail to the client and the family.
- D. Validate that informed consent has been given by the client.
Correct Answer: D
Rationale: The correct answer is D. Validating that informed consent has been given by the client is crucial before any invasive procedure to ensure the client understands the risks, benefits, and alternatives. It also respects the client's autonomy and right to make an informed decision.
A: Measuring oxygen saturation before and after a 12-minute walk is not directly related to thoracentesis preparation.
B: Verifying the client's understanding of complications is important but not the immediate priority before the procedure.
C: Explaining the procedure to the client and family is essential but may not be the first step; ensuring informed consent comes before this step.
Decompression sickness is caused by
- A. a rapid rise of carbon dioxide in the blood.
- B. lack of oxygen in the tissues
- C. bubbles of nitrogen in the blood
- D. glucose deficiency.
Correct Answer: C
Rationale: Decompression sickness occurs when nitrogen bubbles form in the blood due to rapid changes in pressure during ascent. Nitrogen, a major component of air, dissolves in the blood at higher pressure and forms bubbles when pressure decreases. These bubbles can block blood vessels, leading to various symptoms. Choice A is incorrect as it pertains to hypercapnia, not decompression sickness. Choice B is incorrect as decompression sickness is not caused by lack of oxygen but rather by nitrogen bubbles. Choice D is incorrect as glucose deficiency is not related to decompression sickness. Therefore, the correct answer is C, bubbles of nitrogen in the blood.
When does oxyhemoglobin form during respiration?
- A. during external respiration
- B. immediately after carbon dioxide enters the blood
- C. when the chloride shift occurs
- D. during pulmonary ventilation
Correct Answer: A
Rationale: The correct answer is A, during external respiration. Oxyhemoglobin forms when oxygen binds to hemoglobin in the lungs during external respiration. This process occurs in the alveoli where oxygen diffuses from the air sacs into the blood, binding with hemoglobin to form oxyhemoglobin. Choices B, C, and D are incorrect because oxyhemoglobin formation specifically happens during external respiration, not immediately after carbon dioxide enters the blood, when the chloride shift occurs, or during pulmonary ventilation. These processes are important in respiration but do not directly involve the formation of oxyhemoglobin.
Tracheal respiration is found in
- A. Insects and Millipedes
- B. Scorpion and Prawn
- C. Pila and Lobuster
- D. Starfish and Sea cucumber
Correct Answer: A
Rationale: Tracheal respiration is a type of respiration system found in insects and millipedes. This system involves the use of tracheae, which are tiny tubes that deliver oxygen directly to tissues. Insects and millipedes have evolved this efficient respiratory system to support their high metabolic rates. Scorpions and prawns (Choice B), Pila and lobsters (Choice C), and starfish and sea cucumbers (Choice D) do not have tracheal respiration systems. Therefore, the correct answer is A.