Nokea
The physician orders an acid-fast bacilli sputum culture smear on a patient with possible tuberculosis. How will you collect this?
- A. Collect 2 different sputum specimens 12 hours apart
- B. Collect 3 different sputum specimens (one in the morning, afternoon, and at night)
- C. Collect 3 different sputum specimens on 3 different days
- D. Collect 2 different sputum specimens on 2 different days
Correct Answer: C
Rationale: This is how an AFB sputum culture is collected.
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Which is the best response from the nurse?
- A. Tell me more about how you are feeling.
- B. There are lots of things you can still do.
- C. You are just having a bad day today.
- D. What makes you say that?
Correct Answer: A
Rationale: Encouraging the client to express feelings fosters therapeutic communication and helps address emotional concerns related to COPD.
Which of the following signs and symptoms would indicate that the client is experiencing oxygen toxicity? Select all that apply.
- A. Nonproductive cough
- B. Nausea
- C. Restlessness
- D. Headache
- E. Substernal chest pain
- F. Nasal stuffiness
Correct Answer: A, D, E
Rationale: Oxygen toxicity from prolonged high-concentration oxygen can cause a nonproductive cough, headache, and substernal chest pain.
After a chest tube has been inserted to treat the client's pneumothorax, which finding indicates that the chest tube is functioning correctly?
- A. The water in the suction control chamber is bubbling.
- B. The water seal chamber has continuous vigorous bubbling.
- C. The drainage system is positioned upright.
- D. The client reports relief of chest pain.
Correct Answer: D
Rationale: Relief of chest pain indicates the chest tube is effectively re-expanding the lung and resolving the pneumothorax.
Which symptom reported by the client to the nurse is the best indicator that complications are developing from this cold?
- A. Visual stuffiness
- B. Dry cough
- C. High fever
- D. Scratchy throat
Correct Answer: C
Rationale: A high fever suggests a possible secondary bacterial infection or other complication, such as sinusitis or pneumonia, which is more serious than typical cold symptoms.
Which nursing assessment data support that the client has experienced a pulmonary embolism?
- A. Calf pain with dorsiflexion of the foot.
- B. Sudden onset of chest pain and dyspnea.
- C. Left-sided chest pain and diaphoresis.
- D. Bilateral crackles and low-grade fever.
Correct Answer: B
Rationale: Sudden chest pain and dyspnea (B) are classic PE symptoms from hypoxia. Calf pain (A) suggests DVT, left-sided pain (C) suggests MI, and crackles/fever (D) suggest pneumonia.