Nokea
Which of the following nursing actions is most effective in preventing aspiration pneumonia in patients who are at risk?
- A. Turn and reposition immobile patients at least every 2 hours.
- B. Place patients with altered consciousness in side-lying positions.
- C. Monitor for respiratory symptoms in patients who are immuno-suppressed.
- D. Provide for continuous subglottic aspiration in patients receiving enteral feedings.
Correct Answer: B
Rationale: The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings.
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The nurse is caring for a patient with pneumonia who has symptoms of a sharp pain 'whenever I take a deep breath.' Which of the following actions should the nurse take next?
- A. Listen to the patient's lungs.
- B. Administer the PRN morphine.
- C. Have the patient cough forcefully.
- D. Notify the patient's health care provider.
Correct Answer: A
Rationale: The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.
A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. Which of the following information should the occupational health nurse provide to the staff nurse?
- A. Use and adverse effects of isoniazid (INH)
- B. Standard four-drug therapy for TB
- C. Need for annual repeat TB skin testing
- D. Bacille Calmette-Guerin (BCG) vaccine
Correct Answer: A
Rationale: The nurse is considered to have a latent TB infection and should be treated with INH daily for 6-9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is used to prevent TB and is rarely used in Canada, it would not be helpful for this individual, who already has a TB infection.
The nurse is providing teaching to a patient with pulmonary tuberculosis (TB) regarding the transmission of TB. Which of the following patient actions indicate that the teaching has been effective?
- A. Demonstrates correct use of a nebulizer
- B. Washes dishes and personal items after use.
- C. Covers the mouth and nose when coughing.
- D. Reports daily to the public health department.
Correct Answer: C
Rationale: Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB.
The nurse is caring for a patient who has just had a thoracentesis. Which of the following information is most important to communicate to the health care provider?
- A. BP is 150/90 mm Hg.
- B. Oxygen saturation is 89%.
- C. Pain level is 5/10 with a deep breath.
- D. Respiratory rate is 24 when lying flat.
Correct Answer: B
Rationale: Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.
After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first?
- A. A 7-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes
- B. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled
- C. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath
- D. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 37.9 C (100.2 F)
Correct Answer: C
Rationale: Sudden onset shortness of breath in a patient with a deep vein thrombosis suggests a pulmonary embolism and requires immediate assessment and actions such as oxygen administration. The other patients also should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.