Nokea
The occupational health nurse assesses a health care worker's purified protein derivative (PPD) test and measures 11 mm of induration. The nurse should interpret this finding as
- A. A confirmatory test result for pulmonary tuberculosis.
- B. A false-negative test result.
- C. The healthcare worker requires immediate isolation using airborne isolation precautions.
- D. Further testing is required.
Correct Answer: D
Rationale: An 11 mm induration in a healthcare worker indicates a positive PPD test, suggesting TB exposure, but further testing (e.g., chest X-ray, sputum analysis) is needed to confirm active TB. It is not confirmatory for pulmonary TB, not false-negative, and isolation is premature.
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The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 6 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each assessment finding, click to specify if the finding indicates that the client's condition has improved, not changed, or worsened.
- A. Toileting access
- B. Medication organization
- C. Urinary patterns
- D. Activity tolerance
- E. Lower extremities
- F. Bathroom lighting
Correct Answer: A,B,C:Improved;D,E,F:Unchanged
Rationale: Improved toileting access, medication organization, and urinary patterns indicate better management. Activity tolerance, lower extremity symptoms, and bathroom lighting remain unchanged.
The nurse is educating the parents of a child who plans on riding their bicycle. Which statements, if made by the parents, indicate effective understanding?
- A. I should tell my child to ride their bike against the traffic pattern.
- B. I should instruct my child to walk their bike through busy intersection crosswalks.
- C. Wearing a helmet is only necessary when my child is riding near a busy intersection.
- D. My child can ride their bike barefoot as long as it's short distances.
Correct Answer: B
Rationale: Walking the bike through busy intersections enhances safety. Riding against traffic, optional helmet use, and barefoot riding are unsafe.
A newly licensed registered nurse is tasked by a nurse educator to perform a wet-to-dry dressing change on a client with a stage 3 pressure ulcer. Which action would indicate to the nurse educator that the registered nurse is following proper technique?
- A. The registered nurse cleans the ulcer from the outside, rotating into the inside of the ulcer.
- B. The registered nurse packs the incision with sterile gauze, then pours sterile normal saline over the dressing.
- C. The registered nurse packs wet gauze into the ulcer without overlapping it onto the skin.
- D. The registered nurse saturates the old dressing with sterile saline before removing it.
Correct Answer: C
Rationale: Packing wet gauze into the ulcer without overlapping onto the skin ensures effective debridement without irritating healthy tissue. Other options are incorrect techniques.
A nurse is taking care of a client undergoing cerebral angiography. Which statement by the client would require immediate follow-up?
- A. I feel like I'm going to vomit.
- B. I hope my results are okay.
- C. It's getting a bit hot in here.
- D. My throat is getting a bit itchy, and my eyes are getting watery.
Correct Answer: D
Rationale: Itchy throat and watery eyes suggest an allergic reaction to the contrast dye, requiring immediate intervention. Nausea, hopefulness, and feeling warm are less urgent.
The nurse instructed a client discharged with crutches on how to use the stairs. Which statement by the client indicates a correct understanding of the teaching?
- A. I should hold the handrail for support with one hand.
- B. When going up the stairs, I should lead with my crutches and weaker leg.
- C. When going down the stairs, I should lead with my crutches and strong leg.
- D. I should remove the rubber tip when going up and down the stairs.
Correct Answer: A
Rationale: Holding the handrail provides stability. Ascending requires leading with the stronger leg, descending with crutches and weaker leg, and rubber tips remain on.