Nokea
The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test?
- A. Administer intradermal injections into the childrens inner forearms
- B. Administer intramuscular injections into each childs vastus lateralis
- C. Administer a subcutaneous injection into each childs umbilical area
- D. Administer a subcutaneous injection at a 45-degree angle into each childs deltoid
Correct Answer: A
Rationale: The purified protein derivative (PPD) is always injected into the intradermal layer of the inner aspect of the forearm. The subcutaneous and intramuscular routes are not utilized.
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The nurse is caring for an 82-year-old patient with a diagnosis of tracheobronchitis. The patient begins complaining of right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What would you suspect this patient is experiencing?
- A. Traumatic pneumothorax
- B. Empyema
- C. Pleuritic pain
- D. Myocardial infarction
Correct Answer: C
Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases. The scenario does not indicate any trauma to the patient, so a traumatic pneumothorax is implausible. Empyema is unlikely as there is no fever indicative of infection. Myocardial infarction would affect the patients vital signs profoundly.
An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize?
- A. The importance of adhering closely to the prescribed medication regimen
- B. The fact that the disease is a lifelong, chronic condition that will affect ADLs
- C. The fact that TB is self-limiting, but can take up to 2 years to resolve
- D. The need to work closely with the occupational and physical therapists
Correct Answer: A
Rationale: Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable.
The nurse caring for a patient recently diagnosed with lung disease encourages the patient not to smoke. What is the primary rationale behind this nursing action?
- A. Smoking decreases the amount of mucus production
- B. Smoke particles compete for binding sites on hemoglobin
- C. Smoking causes atrophy of the alveoli
- D. Smoking damages the ciliary cleansing mechanism
Correct Answer: D
Rationale: In addition to irritating the mucous cells of the bronchi and inhibiting the function of alveolar macrophage (scavenger) cells, smoking damages the ciliary cleansing mechanism of the respiratory tract. Smoking also increases the amount of mucus production and distends the alveoli in the lungs. It reduces the oxygen-carrying capacity of hemoglobin, but not by directly competing for binding sites.
A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP?
- A. Administration of prophylactic antibiotics
- B. Administration of pneumococcal vaccine to vulnerable individuals
- C. Obtaining culture and sensitivity swabs from all newly admitted patients
- D. Administration of antiretroviral medications to patients over age 65
Correct Answer: B
Rationale: Pneumococcal vaccination reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the general older adult population. A one-time vaccination of pneumococcal polysaccharide vaccine (PPSV) is recommended for all patients 65 years of age or older and those with chronic diseases. Antibiotics are not given on a preventative basis and antiretroviral medications do not affect the most common causative microorganisms. Culture and sensitivity testing by swabbing is not performed for pneumonia since the microorganisms are found in sputum.
A patient who was involved in a workplace accident suffered a penetrating wound of the chest that led to acute respiratory failure. What goal of treatment should the care team prioritize when planning this patients care?
- A. Facilitation of long-term intubation
- B. Restoration of adequate gas exchange
- C. Attainment of effective coping
- D. Self-management of oxygen therapy
Correct Answer: B
Rationale: The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated.