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Your patient is diagnosed with a latent tuberculosis infection. Select all the correct statements that reflect this condition:
- A. The patient will not need treatment unless it progresses to an active tuberculosis infection.
- B. The patient is not contagious and will have no signs and symptoms.
- C. The patient will have a positive tuberculin skin test or IGRA test.
- D. The patient will have an abnormal chest x-ray.
- E. The patient's sputum will test positive for mycobacterium tuberculosis.
Correct Answer: B,C
Rationale: Latent TB infection is characterized by no symptoms, no contagiousness , and a positive tuberculin skin test or IGRA . Treatment is often recommended to prevent progression (not A). Chest X-rays are typically normal (not D), and sputum tests are negative (not E).
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The nurse knows that the correct way to position the hands when performing the abdominal thrust maneuver is with the thumb side of the closed fist on which part of the victim's abdomen?
- A. Directly on the manubrium
- B. Above the xiphoid process
- C. Below the navel
- D. Below the sternum
Correct Answer: B
Rationale: Positioning the fist above the xiphoid process (below the sternum) ensures safe and effective abdominal thrusts to dislodge the obstruction.
A patient has a PPD skin test (Mantoux test). As the nurse you tell the patient to report back to the office in so the results can be interpreted?
- A. 24-48 hours
- B. 12-24 hours
- C. 48-72 hours
- D. 24-72 hours
Correct Answer: C
Rationale: The PPD skin test (Mantoux) is read 48-72 hours after administration to assess for induration, as this is the standard timeframe for an accurate immune response to be visible.
The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube (ET) care?
- A. Do not move or touch the ET tube.
- B. Obtain a chest x-ray daily.
- C. Determine if the ET cuff is deflated.
- D. Ensure that the ET tube is secure.
Correct Answer: D
Rationale: Securing the ET tube (D) prevents dislodgement, critical for ventilation. Avoiding movement (A), daily CXR (B), and cuff deflation (C) are incorrect or secondary.
The nurse is planning the care of a client diagnosed with asthma and has written a problem of 'anxiety.' Which nursing intervention should be implemented?
- A. Remain with the client.
- B. Notify the health-care provider.
- C. Administer an anxiolytic medication.
- D. Encourage the client to drink fluids.
Correct Answer: A
Rationale: Remaining with the client (A) reduces anxiety through presence and reassurance. Notification (B), anxiolytics (C), and fluids (D) are secondary or unrelated.
The client is admitted to the outpatient surgery center for a bronchoscopy to rule out cancer of the lung. Which information should the nurse teach?
- A. The test will confirm the results of the MRI.
- B. The client can eat and drink immediately after the test.
- C. The HCP can do a biopsy of the tumor through the scope.
- D. There is no discomfort associated with this procedure.
Correct Answer: C
Rationale: Bronchoscopy allows biopsy (C) to diagnose lung cancer. It doesn’t confirm MRI (A), requires NPO post-procedure (B), and causes discomfort (D).