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When caring for a patient hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of the patient. Which action, if performed by the student nurse, would require an intervention by the nurse?
- A. The patient is offered a tissue from the box at the bedside.
- B. A surgical face mask is applied before visiting the patient.
- C. A snack is brought to the patient from the unit refrigerator.
- D. Hand washing is performed before entering the patient's room.
Correct Answer: B
Rationale: When caring for a patient with active tuberculosis (TB), it is crucial to use a high-efficiency particulate-absorbing (HEPA) mask instead of a standard surgical mask when entering the patient's room, as a HEPA mask can filter out 100% of small airborne particles, reducing the risk of transmission. Therefore, if the student nurse applies only a surgical face mask before visiting the patient, this action would require intervention by the nurse to ensure the appropriate protective equipment is used. Hand washing before entering the patient's room is essential to prevent the spread of infection and is a correct action. Bringing a snack to the patient from the unit refrigerator is appropriate and helps address potential issues with anorexia and weight loss in patients with TB. While hand washing after handling a tissue used by the patient is necessary, no special precautions are required when offering the patient an unused tissue.
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The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?
- A. Hepatitis testing
- B. Tuberculosis screening
- C. Contraceptive teaching
- D. Colonoscopy information
Correct Answer: B
Rationale: Tuberculosis (TB) is prevalent in many parts of Asia, including Vietnam, and the incidence of TB is higher in immigrants from Vietnam compared to the general U.S. population. Conducting tuberculosis screening is crucial to identify and address any cases promptly, especially in a community with recent immigrants from Vietnam. While teaching about contraceptive use, providing colonoscopy information, and testing for hepatitis may be relevant for certain individuals in the community, they are not as universally important as tuberculosis screening due to the increased risk of TB among Vietnamese immigrants.
A client presents with symptoms of a sore throat, swollen lymph nodes in the neck, fever, chills, and extreme fatigue. Based on these symptoms, which of the following illnesses could the nurse consider for this client?
- A. Methicillin-resistant Staphylococcus aureus (MRSA)
- B. Hepatitis B
- C. Infectious mononucleosis
- D. Norovirus infection
Correct Answer: C
Rationale: Infectious mononucleosis is a viral disease caused by the Epstein-Barr virus. The symptoms of sore throat, fever, chills, swollen lymph nodes, and extreme fatigue are characteristic of infectious mononucleosis. The diagnosis is confirmed through the client's history and blood tests for the Epstein-Barr virus. Methicillin-resistant Staphylococcus aureus (MRSA) presents with localized skin infections, not the systemic symptoms described. Hepatitis B typically presents with jaundice, abdominal pain, and liver inflammation, not the symptoms described. Norovirus infection commonly causes gastrointestinal symptoms like vomiting and diarrhea, not the symptoms presented by the client.
A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
- A. Assist with active range of motion (ROM).
- B. Observe for agitation and paranoia.
- C. Give muscle relaxants as needed to reduce spasms.
- D. Use simple words and phrases to explain procedures.
Correct Answer: A
Rationale: In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.
A pregnant woman who is 36 weeks' pregnant and has hepatitis B is being informed by a nurse. Which of the following statements from the client indicates understanding of this condition?
- A. Now I know my baby will need a cesarean section.
- B. My baby will need two shots soon after birth.
- C. I will not be able to breastfeed.
- D. My baby's father does not need testing; I know I am the one with hepatitis.
Correct Answer: B
Rationale: The correct answer is 'My baby will need two shots soon after birth.' A baby born to a mother with hepatitis B should receive two injections soon after birth to reduce the risk of contracting the disease. Within the first 12 hours post-birth, the baby should receive the first hepatitis B vaccine and hepatitis B immune globulin (HBIG) for additional protection. Option A is incorrect because the need for a cesarean section is not directly related to the mother's hepatitis B status. Option C is incorrect as breastfeeding can be safe if managed properly. Option D is incorrect as the baby's father should also be tested for hepatitis B to prevent transmission to the newborn.
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
- A. A large air leak in the water-seal chamber
- B. 400 mL of blood in the collection chamber
- C. Complaint of pain with each deep inspiration
- D. Subcutaneous emphysema at the insertion site
Correct Answer: B
Rationale: The nurse should be most concerned if 400 mL of blood is observed in the collection chamber as it may indicate the patient is at risk of developing hypovolemic shock. A large air leak in the water-seal chamber is expected initially after chest tube placement for a pneumothorax. While pain with deep inspiration should be treated, it is not as urgent as the risk of continued hemorrhage. Subcutaneous emphysema is not uncommon in a patient with pneumothorax and is usually harmless. However, a large amount of blood in the collection chamber is a more critical finding that requires immediate attention to prevent potential complications.