Nokea
You are assessing your newly admitted patients who are all presenting with atypical signs and symptoms of a possible lung infection. The physician suspects tuberculosis. So, therefore, the patients are being monitored and tested for the disease. Select all the risk factors below that increases a patient's risk for developing tuberculosis:
- A. Diabetes
- B. Liver failure
- C. Long-term care resident
- D. Inmate
- E. IV drug user
- F. HIV
- G. U.S. resident
Correct Answer: C,D,E,F
Rationale: Remember from our lecture we discussed the risk factors for developing TB and to remember them I said remember the mnemonic "TB Risk". It stands for tight living quarters (LTC resident, prison, homeless shelter etc.), below or at the poverty line (homeless), refugee (especially in high risk countries), immune system issue such as HIV, substance abusers (IV drugs or alcohol), Kids less than the age of 5....all these are risk factors.
You may also like to solve these questions
If the client complains of GI side effects associated with rifampin (Rifadin), which nursing action is best?
- A. Administering the drug at night
- B. Giving the drug with food or at mealtimes
- C. Encouraging the client to drink plenty of water
- D. Providing the client with an antacid
Correct Answer: B
Rationale: Giving rifampin with food can reduce gastrointestinal side effects, such as nausea, without compromising its efficacy.
An adult is admitted with chronic obstructive pulmonary disease [COPD]. The nurse notes that he has neck vein distention and slight peripheral edema. The practical nurse notifies the registered nurse and continues frequent assessments because the nurse knows that these signs signal the onset of which of the following?
- A. Pneumothorax
- B. Cor pulmonale
- C. Cardiogenic shock
- D. Left-sided heart failure
Correct Answer: B
Rationale: Neck vein distention and peripheral edema indicate right-sided heart failure, or cor pulmonale, caused by pulmonary hypertension in COPD.
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client diagnosed with a pulmonary embolus. Which data would cause the nurse to question administering the medication?
- A. The client's partial thromboplastin time (PTT) is 38.
- B. The client's international normalized ratio (INR) is 5.
- C. The client's prothrombin time (PT) is 22.
- D. The client's erythrocyte sedimentation rate (ESR) is 10.
Correct Answer: B
Rationale: An INR of 5 (B) is above the therapeutic range (2–3 for pulmonary embolus), indicating excessive anticoagulation and bleeding risk, so warfarin should be questioned. PTT (A) is for heparin, not warfarin. PT (C) alone is not standardized. ESR (D) is irrelevant to anticoagulation.
An adult is to have a thoracentesis performed. What should the nurse do while preparing the client for this procedure?
- A. Keep him NPO for eight hours
- B. Prepare him to go to the operating room
- C. Explain the procedure to him
- D. Administer anticholinergic and analgesic as ordered
Correct Answer: C
Rationale: Explaining the procedure reduces anxiety and ensures the client understands what to expect during thoracentesis.
Select all the factors regarding a deep vein thrombosis that are included in Virchow's Triad:
- A. Hypocoagulability
- B. Atherosclerosis
- C. Endothelial damage
- D. Stasis of venous blood
- E. Excessive coagulability
- F. Increased venous blood flow
Correct Answer: C,D,E
Rationale: Virchow's Triad details the THREE factors (hence why it called a triad) for blood clot formation within the vessel. Remember 'SHE': Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage.