Nokea
The nurse writes a problem of 'impaired gas exchange' for a client diagnosed with cancer of the lung. Which interventions should be included in the plan of care? Select all that apply.
- A. Apply O2 via nasal cannula.
- B. Have the dietitian plan for six (6) small meals per day.
- C. Place the client in respiratory isolation.
- D. Assess vital signs for fever.
- E. Listen to lung sounds every shift.
Correct Answer: A,D,E
Rationale: Oxygen (A), fever assessment (D), and lung sounds (E) address gas exchange in lung cancer. Small meals (B) aid nutrition, not gas exchange, and isolation (C) is unnecessary.
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Your patient with a diagnosis of latent tuberculosis infection needs a bronchoscopy. During transport to endoscopy, the patient will need to wear?
- A. N95 mask
- B. Surgical mask
- C. No special PPE is needed
- D. Face mask with shield
Correct Answer: C
Rationale: Patients with a latent tuberculosis infection are NOT contagious. Therefore, no special PPE is needed for the patient during transport. HOWEVER, if the patient had ACTIVE tuberculosis they would need to wear a surgical mask during transport.
A patient has a PPD skin test (Mantoux test). As the nurse you tell the patient to report back to the office in so the results can be interpreted?
- A. 24-48 hours
- B. 12-24 hours
- C. 48-72 hours
- D. 24-72 hours
Correct Answer: C
Rationale: The PPD skin test (Mantoux) is read 48-72 hours after administration to assess for induration, as this is the standard timeframe for an accurate immune response to be visible.
The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube (ET) care?
- A. Do not move or touch the ET tube.
- B. Obtain a chest x-ray daily.
- C. Determine if the ET cuff is deflated.
- D. Ensure that the ET tube is secure.
Correct Answer: D
Rationale: Securing the ET tube (D) prevents dislodgement, critical for ventilation. Avoiding movement (A), daily CXR (B), and cuff deflation (C) are incorrect or secondary.
An adult client is to have a sputum for culture. When is the best time for the nurse to collect the specimen?
- A. In the morning right after he awakens
- B. Immediately after breakfast
- C. Two hours after eating
- D. Shortly before he retires for the evening
Correct Answer: A
Rationale: The sputum has collected during the night, making it most concentrated and ideal for culture early in the morning.
Other than obtaining a vaccination against influenza, which nursing advice is most helpful to high-risk clients who want to avoid getting influenza?
- A. Consume adequate vitamin C.
- B. Avoid crowded places.
- C. Dress warmly in cold weather.
- D. Reduce daily stress and anxiety.
Correct Answer: B
Rationale: Avoiding crowded places reduces exposure to influenza, a highly contagious respiratory virus.