Nokea
Which agents should the nurse suspect as being the cause of the victims' symptoms? Select all that apply.
- A. Anthrax
- B. Sarin gas
- C. Smallpox
- D. Radiation
- E. Cyanide
- F. Ebola virus
Correct Answer: B, E
Rationale: Sarin gas and cyanide are chemical agents that can cause rapid onset of dyspnea, weakness, and nausea, consistent with the symptoms described.
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Which question is most important for the nurse to ask the client at this time?
- A. When did you last take your prescribed medications?
- B. Have you taken all your medications as prescribed?
- C. How many drug refills have you obtained?
- D. Have you experienced any drug side effects?
Correct Answer: B
Rationale: Asking if the client has taken all medications as prescribed assesses adherence, which is critical for tuberculosis treatment efficacy.
Which diagnostic test should the nurse anticipate the health-care provider ordering to rule out the diagnosis of asthma in clients diagnosed with chronic obstructive pulmonary disease (COPD)?
- A. A bronchoscopy.
- B. An immunoglobulin E.
- C. An arterial blood gas.
- D. A bronchodilator reversibility test.
Correct Answer: D
Rationale: A bronchodilator reversibility test differentiates asthma from COPD by assessing whether airway obstruction is reversible. In asthma, lung function (e.g., FEV1) improves significantly post-bronchodilator, while COPD shows minimal improvement. Bronchoscopy (A) is invasive and not specific for this differentiation. Immunoglobulin E (B) is relevant for allergies, not distinguishing asthma from COPD. Arterial blood gases (C) assess oxygenation but do not differentiate these conditions.
A 48-year old homeless man, who is living in a local homeless shelter and is an IV drug user, has arrived to the clinic to have his PPD skin test assessed. What is considered a positive result?
- A. 5 mm induration
- B. 15 mm induration
- C. 9 mm induration
- D. 10 mm induration
Correct Answer: A
Rationale: For high-risk individuals (e.g., homeless, IV drug users), a PPD induration of ≥5 mm is considered positive due to their increased risk of TB exposure and progression.
The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first?
- A. Administer oxygen 10 L via nasal cannula.
- B. Place the client in high Fowler's position.
- C. Obtain a STAT pulse oximeter reading.
- D. Auscultate the client's lung sounds.
Correct Answer: B
Rationale: High Fowler’s position (B) improves breathing in suspected PE, a priority. Oxygen (A), SpO2 (C), and lung sounds (D) follow to support and assess.
Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply.
- A. Keep protamine sulfate readily available.
- B. Avoid applying pressure to venipuncture sites.
- C. Assess for overt and covert signs of bleeding.
- D. Avoid invasive procedures and injections.
- E. Administer stool softeners as ordered.
Correct Answer: B,C,D
Rationale: Avoiding pressure (B), monitoring bleeding (C), and avoiding procedures (D) prevent hemorrhage during thrombolytics. Protamine (A) reverses heparin, and softeners (E) are unrelated.