Nokea
The nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that Mycobacterium tuberculosis is cultured. How should the nurse correctly analyze these results?
- A. The results are positive for active tuberculosis.
- B. The results indicate a less virulent strain of tuberculosis.
- C. The results are inconclusive until a repeat sputum specimen is sent.
- D. The results are unreliable unless the client has also had a positive tuberculin skin test (TST).
Correct Answer: A
Rationale: Culture of Mycobacterium tuberculosis from sputum or other body secretions or tissue confirms the diagnosis of active tuberculosis.
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A client admitted to the hospital is suspected of having Guillain-Barré syndrome. Which assessment findings should the nurse identify as manifestations of this disorder? Select all that apply.
- A. Dysphagia
- B. Paresthesia
- C. Facial weakness
- D. Difficulty speaking
- E. Hyperactive deep tendon reflexes
- F. Descending symmetrical muscle weakness
Correct Answer: A,B,C,D
Rationale: Guillain-Barré syndrome is an acute autoimmune disorder characterized by varying degrees of motor weakness and paralysis. Motor manifestations include ascending symmetrical muscle weakness that leads to flaccid paralysis without muscle atrophy, decreased or absent deep tendon reflexes, respiratory compromise and respiratory failure, and loss of bladder and bowel control. Sensory manifestations include pain (cramping) and paresthesia. Cranial nerve manifestations include facial weakness, dysphagia, diplopia, and difficulty speaking. Autonomic manifestations include labile blood pressure, dysrhythmias, and tachycardia.
The nurse hangs an intravenous (IV) bag of 1000 mL of 5% dextrose in water (D5W) at 3 pm and sets the flow rate to infuse at 75 mL/hour. At 11 pm, the nurse should expect the fluid remaining in the IV bag to be at approximately which level?
Correct Answer: 400 mL
Rationale: In an 8-hour period, 600 mL would infuse if an IV is set to infuse at 75 mL/hour. Therefore, 400 mL would remain in the IV bag.
A client is admitted after attempting suicide by ingesting a prescribed antipsychotic medication. What is the most important piece of information the nurse should obtain initially?
- A. Where and when the medication was ingested
- B. The name and amount of ingested medication
- C. If the client continues to have suicidal ideations
- D. If there is a history of previous suicidal attempts
Correct Answer: B
Rationale: In an emergency, lifesaving facts are obtained first. The name of and the amount of medication ingested is of utmost importance in treating this potentially life-threatening situation. The remaining data can be assessed once the client's physical condition is stabilized.
A client diagnosed with both a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, which priority intervention should the nurse implement?
- A. Maintaining an intravenous access
- B. Ensuring that oxygen is being delivered
- C. Administering sedation to prevent claustrophobia
- D. Providing emotional support to the client's family
Correct Answer: B
Rationale: Hyperbaric oxygen therapy is a process by which oxygen is administered at greater than atmospheric pressure. When oxygen is inhaled under pressure, the level of tissue oxygen is greatly increased. The high levels of oxygen promote the action of phagocytes and promote healing of the wound. Because the client is placed in a closed chamber, the administration of oxygen is of primary importance. Although options 1, 3, and 4 may be appropriate interventions, option 2 is the priority.
The nurse assesses a peripheral intravenous (IV) dressing and notes that it is damp and the tape is loose. What action should the nurse take initially?
- A. Stop the infusion immediately.
- B. Apply a sterile, occlusive dressing.
- C. Ensure all IV tubing connections are tight.
- D. Gather the supplies needed to insert a new IV.
Correct Answer: C
Rationale: To determine subsequent nursing interventions, the nurse checks all connections to ensure tight seals while the IV infuses to help locate the source of the leak. If the leak is at the insertion site, the nurse stops the infusion, removes the IV, and inserts a new IV catheter. The nurse applies a new sterile occlusive dressing after resolving the source of the leak.