Nokea
Which of the following patients are MOST at risk for developing pneumonia? Select-all-that-apply:
- A. A 53 year old female recovering from abdominal surgery.
- B. A 69 year old patient who recently received the pneumococcal conjugate vaccine.
- C. A 42 year old male with COPD and is on continuous oxygen via nasal cannula.
- D. A 8 month old with RSV (respiratory syncytial virus) infection.
Correct Answer: A,C,D
Rationale: Patients recovering from surgery are at risk due to immobility and impaired cough reflex, those with COPD have chronic lung disease increasing susceptibility, and infants with RSV are prone to secondary bacterial pneumonia. The vaccinated patient has reduced risk due to immunity.
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The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse?
- A. The UAP keeps the chest tube below chest level.
- B. The UAP has the chest tube attached to suction.
- C. The UAP allowed the client out of the bed.
- D. The UAP uses a bedside commode for the client.
Correct Answer: B
Rationale: Suction during ambulation (B) restricts mobility and risks dislodgement, requiring intervention. Below chest level (A), ambulation (C), and commode (D) are appropriate.
A patient has a positive PPD skin test that shows an 8 mm induration. As the nurse you know that:
- A. The patient will need to immediately be placed in droplet precautions and started on a medication regime.
- B. The patient will need a chest x-ray and sputum culture to confirm the test results before treatment is provided.
- C. The patient will need an IGRA test to help differentiate between a latent tuberculosis infection versus an active tuberculosis infection.
- D. The patient will need to repeat the skin test in 48-72 hours to confirm the results.
Correct Answer: B
Rationale: A positive PPD result does NOT necessarily mean the patient has an active infection of TB. The patient will need a chest x-ray and sputum culture to determine if mycobacterium tuberculosis is present and then treatment will be based on those results. The IGRA test does NOT differentiate between LTBI or an active TB infection. Patients are placed in airborne precautions (NOT droplet) if they have ACTIVE TB.
An adult with tuberculosis has started taking rifampin (Rimactane). Which side effect is the client most likely to experience when taking this drug?
- A. Reddish-orange color of urine, sputum, and saliva
- B. Erythema and urticaria
- C. Tinnitus and deafness
- D. Peripheral neuritis
Correct Answer: A
Rationale: Rifampin commonly causes a harmless reddish-orange discoloration of body fluids.
When the nurse is teaching a client to self-administer nose drops, which head position is appropriate?
- A. Bending the head forward, then instilling the drops
- B. Pushing the nose laterally, then instilling the drops
- C. Tilting the head backward, then instilling the drops
- D. Turning the head to the side, then instilling the drops
Correct Answer: C
Rationale: Tilting the head backward allows nose drops to reach the nasal passages effectively by gravity, ensuring proper distribution of the medication.
After levalbuterol hydrochloride (Xopenex) administration, which client symptom does the nurse evaluate as a side effect of the medication?
- A. Respiratory rate of 28 breaths/minute
- B. Heart rate of 96 beats/minute
- C. Blood pressure of 100/60 mm Hg
- D. Drowsiness
Correct Answer: B
Rationale: Levalbuterol, a beta-agonist, commonly causes an increased heart rate as a side effect due to its stimulatory effects.