Nokea
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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Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment?
- A. Check the amount of wall suction being applied.
- B. Assess the tubing for blood clots.
- C. Milk the tubing proximal to distal.
- D. Encourage the client to cough forcefully.
Correct Answer: A
Rationale: Excessive bubbling suggests an air leak or high suction; checking suction (A) is first. Clots (B), milking (C), and coughing (D) are secondary or inappropriate.
A 62-year-old man is admitted with emphysema and acute upper respiratory infection. Oxygen is ordered at 2 L/min. The reason for low-flow oxygen is to:
- A. prevent excessive drying of secretions.
- B. facilitate oxygen diffusion of the blood.
- C. prevent depression of the respiratory drive.
- D. compensate for increased airway resistance.
Correct Answer: C
Rationale: In COPD, low oxygen levels drive respiration. Low-flow oxygen prevents suppression of the respiratory drive, which could occur with high-flow oxygen.
Other than obtaining a vaccination against influenza, which nursing advice is most helpful to high-risk clients who want to avoid getting influenza?
- A. Consume adequate vitamin C.
- B. Avoid crowded places.
- C. Dress warmly in cold weather.
- D. Reduce daily stress and anxiety.
Correct Answer: B
Rationale: Avoiding crowded places reduces exposure to influenza, a highly contagious respiratory virus.
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 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.