Chapter 27 & 28: Lower Respiratory Problems

17. The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include? a. Options for smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for lung cancer

ANS: A Because smoking is the major cause of lung cancer, the most important role for the nurse is teaching patients about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk patients. However, if there is a positive finding, the person already has lung cancer. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer

43. Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider? a. Cough productive of bloody, purulent mucus b. Scattered crackles and wheezes heard bilaterally c. Complaint of sharp chest pain with deep breathing d. Respiratory rate 28 breaths/minute while ambulating

ANS: A Hemoptysis may indicate life-threatening hemorrhage, and should be reported immediately to the health care provider. The other findings are frequently noted in patients with bronchiectasis and may need further assessment but are not indicators of life-threatening complications. Page 581 11th edition Teach patients when to contact the HCP if hemoptysis occurs. Some patients may periodically expectorate a "spot" of blood that is usual for them and do not require urgent attention. However, if the patient expectorates a moderate to large amount of blood, they should contact the HCP at once. Page 581 11th edition Clinical Manifestations The hallmark is persistent cough with consistent production of thick, tenacious, purulent sputum. In rare situations, some patients with severe disease and upper lobe involvement may have no sputum production and little cough. Recurrent infections injure blood vessels. Large connections (anastomoses) may develop between blood vessels in the lungs, and hemoptysis may occur. In severe cases the bleed can be life-threatening. Other manifestations are pleuritic chest pain, dyspnea, wheezing, clubbing of digits, weight loss, and anemia. On auscultation, adventitious sounds can be heard (e.g., crackles, wheezes).

A patient who has bronchiectasis asks the nurse, "What conditions would warrant a call to the clinic?" a. Blood clots in the sputum b. Sticky sputum on a hot day c. Increased shortness of breath after eating a large meal d. Production of large amounts of sputum on a daily basis

ANS: A If hemoptysis occurs, patients should know when they should contact the HCP. In some patients, a spot of blood is usual. The HCP should give explicit instructions about when emergency contact is needed. The other indicators are to be expected in the patient with bronchiectasis, and do not need urgent medical attention. Page 581 11th edition Teach patients when to contact the HCP if hemoptysis occurs. Some patients may periodically expectorate a "spot" of blood that is usual for them and do not require urgent attention. However, if the patient expectorates a moderate to large amount of blood, they should contact the HCP at once.

31. The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. Oxygen saturation is 88%. b. Blood pressure is 145/90 mm Hg. c. Respiratory rate is 22 breaths/minute when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

ANS: A Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88% 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 Page 530 11th editon A chest x-ray may be done after the procedure to assess for complications, such as pneumothorax. During and after the procedure, monitor vital signs and pulse oximetry. Observe the patient for respiratory distress.

42. A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate breath sounds. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

ANS: A 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 and/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 Page 531 11th edition Pleurisy (pleuritis) is an inflammation of the pleura. It can be caused by infectious diseases, cancer, autoimmune disorders, chest trauma, GI disease, and certain medications. The inflammation usually subsides with adequate treatment of the primary disease. The pain of pleurisy is typically abrupt, sharp in onset, and worse with inspiration. The patient's breathing is shallow and rapid to avoid unnecessary movement of the pleura and chest wall. A pleural friction rub may occur. This is the sound heard over areas where inflamed visceral pleura and parietal pleura rub over one another during inspiration. This sound, like a squeaking door, is usually loudest at peak inspiration. It may be heard during exhalation as well. Treatment of pleurisy is aimed at treating the underlying disease and providing pain relief. Teach the patient to splint the rib cage when coughing. If the pain is severe, intercostal nerve blocks may be considered.

11. An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? a. Yellow-tinged skin b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices

ANS: A Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the oxygen saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider

ANS: A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done

15. When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. Which action, if performed by the student nurse, would require an intervention by the nurse? a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patient's room.

ANS: B A high-efficiency particulate-absorbing (HEPA) mask (N95 mask), rather than a standard surgical mask, should be used when entering the patient's room because the HEPA/N95 mask can filter out 100% of small airborne particles. Hand washing before entering the patient's room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue

45. An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? a. Listening to the patient's lung sounds several times during the shift b. Placing the patient on droplet precautions and in a private hospital room c. Increasing the oxygen flow rate to keep the oxygen saturation above 90% d. Monitoring patient serology results to identify the specific infecting organism

ANS: B Fungal infections are not transmitted from person to person. Therefore no isolation procedures are necessary. The other actions by the new nurse are appropriate. Page 515 11th edition Pulmonary fungal infections are acquired by inhaling spores. They are not transmitted from person to person. The patient does not have to be placed in isolation. Pulmonary fungal pneumonia is an infectious process in the lungs caused by endemic (native and common) or opportunistic fungi (Table 27.14). Endemic fungal pathogens cause infection in healthy people and in immunocompromised people in certain geographic locations in the United States. For example, Coccidioides, which causes coccidioidomycosis, is a fungus found in the soil of dry, low-rainfall areas. It is endemic in many areas of the southwestern United States. Opportunistic fungal infections occur in immunocompromised patients (e.g., those receiving chemotherapy, immunosuppressive drugs) and in patients with HIV and cystic fibrosis. These pulmonary fungal infections can be life-threatening.

When caring for a patient with a lung abscess, what is the nurse's priority intervention? a. Postural drainage b. Antibiotic administration c. Obtaining a sputum specimen d. Patient teaching about home care

ANS: B IV antibiotic therapy should be started as soon as possible. Postural drainage is not recommended because it may spread infection into other bronchi. Findings in a sputum specimen are not diagnostic for a lung abscess. (Page 516 11th edition. expectorated sputum samples are contaminated with oral flora, making it hard to determine the responsible organism(s). Pleural fluid and blood cultures may be useful to identify the offending organisms). Teaching about home care is important but not the priority.

37. The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)

ANS: B Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as oxygen administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration

9. The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. "I will avoid being outdoors whenever possible." b. "My husband will be sleeping in the guest bedroom." c. "I will take the bus instead of driving to visit my friends." d. "I will keep the windows closed at home to contain the germs."

ANS: B Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation

13. After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Teach about treatment for drug-resistant TB treatment. b. Ask the patient whether medications have been taken as directed. c. Schedule the patient for directly observed therapy three times weekly. d. Discuss with the health care provider the need for the patient to use an injectable antibiotic.

ANS: B The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed

7. The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach about the need to get sputum specimens for 2 to 3 consecutive days. d. Instruct the patient to expectorate three specimens as soon as possible.

ANS: C Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB Page 512 11th edition Bacteriologic Studies Culture is the gold standard for diagnosing TB. Three consecutive sputum specimens are needed, each collected at 8- to 24-hour intervals, with at least 1 early morning specimen.

28. A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? a. Start a peripheral IV line to administer the necessary sedative drugs. b. Position the patient sitting upright on the edge of the bed and leaning forward. c. Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. d. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.

ANS: B When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema Page 530 11th edition Thoracentesis is aspiration of intrapleural fluid for diagnostic and therapeutic purposes. For a thoracentesis, the patient may sit on the edge of a bed and lean forward over a bedside table. A chest x-ray or ultrasound images are used to determine the optimal puncture site. Page 531 11th edition Pleural effusion is an abnormal collection of fluid in this space. It is not a disease but a sign of disease. (This was on the exam)

6. The nurse is monitoring for liver toxicity in a patient who has been receiving long-term isoniazid therapy. Manifestations of liver toxicity which of these? (Select all that apply.) a. Orange discoloration of sweat and tears. b. Darkened urine. c. Dizziness. d. Fatigue. e. Visual disturbances. f. Jaundice.

ANS: B, D, F

1. The nurse is providing patient teaching for a patient who is starting antitubercular drug therapy. Which of these statements should be included? (Select all that apply.) a. "Take the medications until the symptoms disappear." b. "Take the medications at the same time every day." c. "You will be considered contagious during most of the illness and must take precautions to avoid spreading the disease." d. "Stop taking the medications if you have severe adverse effects." e. "Avoid alcoholic beverages while on this therapy." f. "If you notice reddish-brown or reddish-orange urine, stop taking the drug and contact your doctor right away." g. "If you experience a burning or tingling in your fingers or toes, report it to your prescriber immediately." h. "Oral contraceptives may not work while you are taking these drugs, so you will have to use another form of birth control."

ANS: B, E, G, H Medications for tuberculosis must be taken on a consistent schedule to maintain blood levels. Medication therapy for tuberculosis may last up to 24 months, long after symptoms disappear, and patients are infectious during the early part of the treatment. Compliance with antitubercular drug therapy is key, so if symptoms become severe, the prescriber should be contacted for an adjustment of the drug therapy. The medication must not be stopped. Because of potential liver toxicity, patients on this drug therapy must not drink alcohol. Discoloration of the urine is an expected adverse effect, and patients need to be warned about it beforehand. Burning or tingling in the fingers or toes may indicate that peripheral neuropathy is developing, and the prescriber needs to be notified immediately. A second form of birth control must be used because antitubercular drug therapy makes oral contraceptives ineffective.

40. The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

ANS: C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given

33. A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest-x-ray showed infiltrates in the lower lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.

ANS: C Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.

10. A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse? a. Ask if the patient is experiencing shortness of breath, hives, or itching. b. Ask the patient about any visual abnormalities such as red-green color discrimination. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider.

ANS: C Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol (Myambutol), which is a different TB medication Page 512 11th edition rifampin (Rifadin) Common Side Effects - Hepatotoxicity, thrombocytopenia, - Orange discoloration of bodily fluids (sputum, urine, sweat, tears) - Anorexia, nausea, abdominal discomfort

16. An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease? a. Treat workers with pulmonary fibrosis. b. Teach about symptoms of lung disease. c. Require the use of protective equipment. d. Monitor workers for coughing and wheezing.

ANS: C Prevention of lung disease (Environmental Lung Diseases) requires the use of appropriate protective equipment (PPE) such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation. Page 517 11th edition The best approach to managing environmental lung diseases is to prevent or decrease environmental and occupational exposure. Teach those at risk about the use of appropriate personal protective equipment. Wearing masks and using well-designed, effective ventilation systems are appropriate for some occupations and household activities.

14. Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse? a. Standard four-drug therapy for TB b. Need for annual repeat TB skin testing c. Use and side effects of isoniazid (INH) d. Bacille Calmette-Guérin (BCG) vaccine

ANS: C The nurse is considered to have a latent TB infection and should be treated with isoniazid (INH) daily for 6 to 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 not used in the United States for TB and would not be helpful for this individual, who already has a TB infection Page 513 11th edition The standard treatment regimen for LTBI is 9 months of daily isoniazid. It is an effective and inexpensive drug that the patient can take orally. While the 9-month regimen is more effective, adherence issues may make a 6-month regimen preferable.

6. The nurse is counseling a woman who will be starting rifampin (Rifadin) as part of antitubercular therapy. The patient is currently taking oral contraceptives. Which statement is true regarding rifampin therapy for this patient? a. Women have a high risk for thrombophlebitis while on this drug. b. A higher dose of rifampin will be necessary because of the contraceptive. c. Oral contraceptives are less effective while the patient is taking rifampin. d. The incidence of adverse effects is greater if the two drugs are taken together.

ANS: C Women taking oral contraceptives and rifampin need to be counseled about other forms of birth control because of the impaired effectiveness of the oral contraceptives during concurrent use of rifampin. Pharmacology book pg 654 Women taking oral contraceptives who are prescribed rifampin must be switched to another form of birth control. Oral contraceptives become ineffective when given with rifampin.

A patient with TB has been admitted to the hospital and is placed on airborne precautions and in an isolation room. What should the nurse teach the patient? (select all that apply) a. Expect routine TB testing to evaluate the infection. b. No visitors will be allowed while in airborne isolation. c. Adherence to precautions includes coughing into a paper tissue. d. Take all medications for full length of time to prevent multidrug-resistant TB. e. Wear a standard isolation mask if leaving the airborne infection isolation room.

ANS: C, D, E To reduce antibiotic-resistant tuberculosis, patients must take multiple drugs for a minimum of 3 months. If patients need to be out of the negative-pressure room, they must wear a standard isolation mask to prevent exposure to others. Teach patients to cover the nose and mouth with paper tissue every time they cough, sneeze, or produce sputum. If a person has a positive reaction to the tuberculin skin test, he or she does not need to be tested again because the sensitivity to tuberculin persists throughout life. Nurses and visitors must wear high-efficiency particulate air (HEPA/N95) masks when entering the patient's room.

12. An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Arrange for a friend to administer the medication on schedule. b. Give the patient written instructions about how to take the medications. c. Teach the patient about the high risk for infecting others unless treatment is followed. d. Arrange for a daily noon meal at a community center where the drug will be administered.

ANS: D Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient. Page 513 11th edition Directly observed therapy (DOT) involves providing the antitubercular drugs directly to patients and watching as they swallow the medications. To ensure adherence, it is the preferred strategy for all patients with TB, especially for those at risk for nonadherence. Nonadherence is a major factor in the emergence of MDR-TB and treatment failures. Many people do not adhere to the treatment program despite understanding the disease process and value of treatment.

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? a. Teach the patient to avoid the use of over-the -counter expectorants. b. Assist the patient with chest physiotherapy and postural drainage. c. Notify the health care provider immediately about any bloody or foul-smelling sputum. d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

ANS: D Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough. Page 516 11th edition Because of the need for prolonged antibiotic therapy, the patient must be aware of the importance of continuing the medication for the prescribed period. To avoid the risk for a secondary or worsening infection, all antibiotics should be taken as directed for the entire prescribed period. Sometimes the patient is asked to return periodically during the course of antibiotic therapy for repeat cultures and sensitivity tests to ensure that the infecting organism is not becoming resistant to the antibiotic. When antibiotic therapy is complete, the patient is reevaluated.

8. A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.

ANS: D Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment

1. The nurse is discussing adverse effects of antitubercular drugs with a patient who has active tuberculosis. Which potential adverse effect of antitubercular drug therapy should the patient report to the prescriber? a. Gastrointestinal upset b. Headache and nervousness c. Reddish-orange urine and stool d. Numbness and tingling of extremities

ANS: D Patients on antitubercular therapy should report experiencing numbness and tingling of extremities, which may indicate peripheral neuropathy. Some drugs may color the urine, stool, and other body secretions reddish-orange, but this is not an effect that needs to be reported. Patients need to be informed of this expected effect. The other options are incorrect. Pharmacology book page 650 Isoniazid Side effect: Peripheral neuropathy, hepatotoxicity, optic neuritis, and visual disturbances, hyperglycemia Pharmacology book page 653 The prescriber must be notified if there are signs and symptoms of peripheral neuropathy (e.g., numbness, burning, and tingling of extremities). Pyridoxine (vitamin B6) may be beneficial for isoniazid-induced peripheral neuropathy.

38. The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test? a. "Is there any family history of TB?" b. "How long have you lived in the United States?" c. "Do you take any over-the-counter (OTC) medications?" d. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?"

ANS: D Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing Page 514 11th edition The vaccine is given to infants in parts of the world with a high prevalence of TB. In the United States, it is typically not used because of the low risk for infection, the vaccine's variable effectiveness against adult pulmonary TB, and potential interference with TB skin test reactivity. The BCG vaccination can result in a false-positive TST.

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."

ANS: D Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis Page 531 11th edition deep-breathing exercises, coughing, incentive spirometry, and early mobility are important to prevent atelectasis

3. The nurse will assess the patient for which potential contraindication to antitubercular therapy? a. Glaucoma b. Anemia c. Heart failure d. Hepatic impairment

ANS: D Results of liver function studies (e.g., bilirubin level, liver enzyme levels) need to be assessed because isoniazid and rifampin may cause hepatic impairment; severe liver dysfunction is a contraindication to these drugs. In addition, the patient's history of alcohol use needs to be assessed. Book page 512 Rifampin (Rifadin) Common side effects - Hepatotoxicity, thrombocytopenia, - Orange discoloration of bodily fluids (sputum, urine, sweat, tears) - Anorexia, nausea, abdominal discomfort Book page 512 Isoniazid Common side effects - Hepatotoxicity, asymptomatic elevation of aminotransferases (ALT, AST) - Vomiting, confusion, headaches Drug Alert Isoniazid • Alcohol may increase risk for hepatotoxicity. • Teach patient to avoid drinking alcohol during treatment. • Monitor for signs of hepatitis before and while taking drug.

True or False: Tuberculosis is a contagious bacterial infection caused by mycobacterium tuberculosis and it only affects the lungs. True False

Answer: FALSE Tuberculosis is a contagious bacterial infection caused by mycobacterium tuberculosis that affects the lungs AND other systems of the body like the joints, kidneys, brain, spine, liver etc. From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

A 52-year old female patient is receiving medical treatment for a possible tuberculosis infection. The patient is a U.S. resident but grew-up in a foreign country. She reports that as a child she received the BCG vaccine (bacille Calmette-Guerin vaccine). Which physician's order below would require the nurse to ask the doctor for an order clarification? A. PPD (Mantoux test) B. Chest X-ray C. QuantiFERON-TB Gold (QFT) D. Sputum culture

The answer is A. Patients who have received the BCG vaccine will have a false positive on a PPD (Mantoux test), which is the tuberculin skin test. The BCG vaccine is a vaccine to prevent TB. It is given in foreign countries to children to prevent TB. Therefore, the person has already been exposed to the bacteria via vaccine and will have a false positive. A QuantiFERON-TB Gold test is a better option for this patient. It is a blood test. From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

A 55-year old male patient is admitted with an active tuberculosis infection. The nurse will place the patient in ___________________ precautions and will always wear _____________________ when providing patient care? A. droplet, respirator B. airborne, respirator C. contact and airborne, surgical mask D. droplet, surgical mask

The answer is B. A patient with ACTIVE TB is contagious. The bacterium, mycobacterium tuberculosis which causes TB, is so small that it can stay suspended in the air for hours to days. Therefore, the nurse will place the patient in AIRBORNE precautions. In addition, a special mask must be worn called a respirator (also referred to as an N95 mask.....a surgical mask does NOT work with this condition From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

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.

The answer is B. 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. From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

Which statement is correct regarding mycobacterium tuberculosis? A. This bacterium is an anaerobic type of bacteria. B. It is an alkali bacterium that stains bright red during an acid-fast smear test. C. It is known as being an aerobic type of bacteria. D. It's an acid-fast bacterium that stains bright green during an acid-fast smear test.

The answer is C. Mycobacterium tuberculosis is AEROBIC (it thrives in conditions that are high in oxygen), and it is an ACID-FAST bacterium, which means when it is stained during an acid-fast smear it will turn BRIGHT RED. From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

Your patient with a diagnosis of latent tuberculosis infection needs a bronchoscopy. During transport to endoscopy, the patient will need to wear? A. N95 mask B. Surgical mask C. No special PPE is needed D. Face mask with shield

The answer is C. Patients with a latent tuberculosis infection are NOT contagious. Therefore, no special PPE is needed for the patient during transport. HOWEVER, if the patient had ACTIVE tuberculosis they would need to wear a surgical mask during transport. From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

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

The answer is C. The patient should report back in 48-72 hours. If they fail to, the test must be repeated. Page 511, 11th edition The test is read by inspection and palpation 48 to 72 hours later for the presence or absence of induration. Induration, a palpable, raised, hardened area or swelling (not redness) at the injection site means the person has been exposed to TB and has developed antibodies. From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

The physician orders an acid-fast bacilli sputum culture smear on a patient with possible tuberculosis. How will you collect this? A. Collect 2 different sputum specimens 12 hours apart B. Collect 3 different sputum specimens (one in the morning, afternoon, and at night) C. Collect 3 different sputum specimens on 3 different days D. Collect 2 different sputum specimens on 2 different days

The answer is C. This is how an AFB sputum culture is collected. Book pg 512 Bacteriologic Studies Culture is the gold standard for diagnosing TB. Three consecutive sputum specimens are needed, each collected at 8- to 24-hour intervals, with at least 1 early morning specimen. The initial test involves a microscopic examination of stained sputum smears for AFB. A definitive diagnosis of TB requires mycobacterial growth, which can take up to 6 weeks. Treatment is needed pending the culture results for patients in whom suspicion of TB is high. From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

A patient taking Isoniazid (INH) should be monitored for what deficiency? A. Vitamin C B. Calcium C. Vitamin B6 D. Potassium

The answer is C. This medication can lead to low Vitamin B6 levels. Most patients will take a supplement of B6 while taking this medication. Book page 512 Isoniazid Common side effects - Hepatotoxicity, asymptomatic elevation of aminotransferases (ALT, AST) - Vomiting, confusion, headaches Drug Alert Isoniazid • Alcohol may increase risk for hepatotoxicity. • Teach patient to avoid drinking alcohol during treatment. • Monitor for signs of hepatitis before and while taking drug. Pharmacology Book pg 654 Vitamin B6 is needed to combat the peripheral neuropathy associated with isoniazid. Pharmacology book page 650 Isoniazid Side effect: Peripheral neuropathy, hepatotoxicity, optic neuritis, and visual disturbances, hyperglycemia From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

As the nurse you know that one of the reasons for an increase in multi-drug-resistant tuberculosis is: A. Incorrect medication ordered B. Increase in tuberculosis cases nationwide C. Incorrect route of drug ordered D. Noncompliance due to duration of medication treatment needed

The answer is D. Patients must be on medication treatment for about 6-12 months (depending on the type of TB the patient has). This leads to noncompliant issues. DOT (directly observed therapy) is now being instituted so compliance is increased. This is where a public health nurse or a trained DOT worker will deliver the medication and watch the patient swallow the pill until treatment is complete. From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

You note your patient's sweat and urine is orange. You reassure the patient and educate him that which medication below is causing this finding? A. Ethambutol B. Streptomycin C. Isoniazid D. Rifampin

The answer is D. This medication will cause body fluids to turn orange. Book page 512 Rifampin (Rifadin) Common side effects - Hepatotoxicity, thrombocytopenia, - Orange discoloration of bodily fluids (sputum, urine, sweat, tears) - Anorexia, nausea, abdominal discomfort From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

A patient receiving medical treatment for an active tuberculosis infection asks when she can start going out in public again. You respond that she is no longer contagious when: (Select all that apply) A. She has 3 negative sputum cultures B. Her signs and symptoms improve C. She has completed the full medication regime D. Her chest x-ray is normal E. She has been on tuberculosis medications for about 3 weeks

The answers are A, B, and E. These are all criteria for when a patient with active TB can return to public life (school, work, running errands). Until then they are still contagious and must stay home in isolation. From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

Your patient is diagnosed with a latent tuberculosis infection. Select all the correct statements that reflect this condition: (Select all that apply) 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 (blood test). D. "The patient will have an abnormal chest x-ray." E. "The patient's sputum will test positive for mycobacterium tuberculosis."

The answers are B and C. The patient WILL need medical treatment to prevent this case of latent tuberculosis infection (LTBI) from developing into an active TB infection later on. The patient will NOT have an abnormal chest x-ray or a positive sputum test. This is only in active TB. See TABLE 27.9 (page 511 in 11th edition) Latent Tuberculosis Infection (LTBI) Compared to Tuberculosis Disease From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

You're teaching a group of long-term care health givers about the signs and symptoms of tuberculosis. What signs and symptoms will you include in your education? (Select all that apply) A. Cough for a minimum of 6 weeks B. Night sweats C. Weight gain D. Hemoptysis E. Chills F. Fever G. Chest pain H. Fatigue

The answers are B, D, E, F, G, and H. Option A is wrong because a cough should be present for 3 weeks or more (NOT 6 weeks). Option C is wrong because the patient will experience weight LOSS (not gain). From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/

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: (Select all that apply) A. Diabetes B. Liver failure C. Long-term care resident D. Inmate E. IV drug user F. HIV G. U.S. resident

The answers are C, D, E, and F. 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 (Lont-term care 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. From RegisteredNurseRN www.youtube.com/watch?v=Or9EncdUbx8 https://www.registerednursern.com/tuberculosis-nclex-questions/