nur 111 - edge - Tuberculosis
Which discharge teaching should the nurse include in the teaching plan for a client who was treated for tuberculosis? Select all that apply. "Family members should have chest x-rays done." "Stop medication when coughing subsides." "Persons living with you should have skin testing." "Use your best judgment in terms of your daily medications." "Maintain adequate nutrition."
"Persons living with you should have skin testing." "Maintain adequate nutrition."
The nurse should include which priority preventive measure when teaching a group of adults about preventing the spread of tuberculosis? -Handwashing -Annual vaccination -Isolation -Covering mouth when coughing
-Isolation
Which type of room should the William be placed in when transferred from the waiting room to an ED room? -A client room with negative airflow capability. -A multiple client room with curtains for privacy. -A client room with contact precaution capability. -A semi-private room with another client with respiratory symptoms.
A client room with negative airflow capability. CORRECT. A client who presents with symptoms of TB should be placed in a client room with negative airflow capability as soon as possible. In this type of room, air circulates into the contaminated area of the client's room from surrounding areas. A multiple client room is not appropriate as the client with TB is contagious. The client suspected of having TB should never be placed in a room with other clients. All client rooms include contact precautions.
The nurse applies this mask before entering a patient's room. What is the name of this mask? -N95 -Isolation mask -Simple mask -Body fluid mask
N95 Rationale: The institution of airborne precautions, the use of an N95 mask respirator for healthcare personnel entering the patient's room (requires fit-testing), and a snug-fitting surgical mask for visitors are essential interventions. Rationale: An isolation mask is not protective against airborne infections. Rationale: A simple mask is used for the delivery of oxygen. Rationale: There is no such thing as a body fluid mask. Test Taking Tips: Look closely at the image.
The nurse is teaching about the pathophysiology of tuberculosis (TB). Which statement made is correct? "Destruction of the lung tissue occurs in the patient during granuloma formation." Pleuritic chest pain is the result of the sputum present." "The unexplained weight loss is due to the destruction of lung tissue." "Micro bleeds are the result of the collection of white blood cells in an attempt to wall off the infection."
"Destruction of the lung tissue occurs in the patient during granuloma formation." Rationale: Destruction of the lung tissue occurs in a patient during granuloma formation. Rationale: Pleuritic chest pain is the result of chronic coughing. Rationale: The unexplained weight loss is due to the inflammatory response, specifically the body's attempt to interact with the mycobacterium. Rationale: Sputum is the result of the collection of white blood cells present in an attempt to wall off the infection. Test Taking Tips: Consider the pathophysiology.
The nurse is teaching about the epidemiology of tuberculosis (TB). Which statements indicated the need for further teaching? Select all that apply. "Tuberculosis (TB) is present in foreign-born individuals." "Low socioeconomic groups are the most affected." "The most affected age groups vary from 40 to 60 years old." "About half of the HIV-infected population in the United States is affected by Mycobacterium tuberculosis." "Individuals with AIDS are the most prone to TB."
"The most affected age groups vary from 40 to 60 years old." "About half of the HIV-infected population in the United States is affected by Mycobacterium tuberculosis." Rationale: The most affected age groups vary from 25 to 45 years of age. Rationale: About one third of the total HIV-infected population in the United States is affected by M tuberculosis. Rationale: Foreign-born individuals have the highest incidence of reported TB. Rationale: Individuals with AIDS are essentially the most prone to TB. Test Taking Tips: Look for the incorrect answers.
The nurse is preparing to conduct the admission assessment now that William is settled into the room after transport. Which findings should the nurse anticipate when conducting the client's respiratory assessment? Select all that apply. -Clear breath sounds -Audible wheezing -Eupnea (normal respiration) -Rales (discontinuous crackle and pop sounds) -Rhonchi (rattling sounds)
-Audible wheezing -Rales (discontinuous crackle and pop sounds) -Rhonchi (rattling sounds) CORRECT. When conducting a respiratory assessment for a client who is diagnosed with TB, you should anticipate audible wheezes, rales, and rhonchi. It is unlikely that the client's breath sounds are clear or that the client is experiencing eupnea, or normal respirations.
The nurse is caring for a client with a diagnosis of active tuberculosis. Which symptoms does the nurse expect this client to exhibit? Select all that apply. -Fever -Abdominal rigidity -Abnormal breathing sounds -Hypothermia -Decreased oxygen saturation
-Fever -Abnormal breathing sounds -Decreased oxygen saturation
Which nursing actions are appropriate when caring for a client diagnosed with tuberculosis? Select all that apply. -Place on droplet precautions. -Humidify oxygen when administered. -Request dietary consult. -Offer family members N95 masks. -Medication teaching.
-Humidify oxygen when administered. -Request dietary consult. -Medication teaching.
Which instruction should the nurse provide to a client who has just received a PPD (purified protein derivative)? -Return to the clinic in 48-72 hours to have the test read. -Take antiviral medication as prescribed. -Massage the subcutaneous injection site. -There may be a very small amount of bleeding on the forearm.
-Return to the clinic in 48-72 hours to have the test read.
The nurse is assessing a patient with tuberculosis (TB). Which best describes the gas exchange in the patient? -Alteration in gas exchange related to necrosis of lung tissue -Alteration in comfort: pain related to pleurisy -Risk for fluid volume deficit related to insensible losses from fever and tachypnea -Alteration in gas exchange: decreased related to impaired alveolar-capillary interface
Alteration in gas exchange related to necrosis of lung tissue Rationale: Necrosis of lung tissue is related to a nursing diagnosis of gas exchange in a patient suffering from tuberculosis. Rationale: Pain related to pleurisy leads to discomfort in a patient suffering from tuberculosis. Rationale: Insensible losses from fever and tachypnea lead to fluid volume deficit in a patient suffering from influenza. Rationale: Impaired alveolar-capillary interface leads to decreased gas exchange in a patient with influenza. Test Taking Tips: Consider the pathophysiology.
The nurse is providing care to William Parish, who presents in the emergency department with symptoms indicative of tuberculosis (TB).Which action should the nurse take when triaging William upon his arrival to the emergency department? -Ask William to wear a gown while in the waiting area. -Ask William to wear gloves until transferred to a room. -Ask William to place a face mask over his mouth and nose. -Ask William to use hand sanitizer after using the restroom.
Ask William to place a face mask over his mouth and nose. CORRECT. Any client who presents with symptoms that are indicative of TB should be asked to wear a face mask until he or she is transferred to a room. TB is highly contagious and transferred via droplets in the air; therefore, placing a face mask on the client decreases the risk of transmission to others prior to placing the client in an appropriate room for airborne precautions.
Which safety measures followed by the nurse when caring for a patient with suspected tuberculosis (TB) infection can cause the spread of pathogens to other individuals? -Keeping the patient isolated in a private room with negative airflow -Donning an N95 mask respirator when entering the patient's private room -Instructing the visitors to wear a snug-fitting surgical mask when entering the patient's private room -Ensuring that the patient leaves the negative pressure room connected to a SPO2 probe
Ensuring that the patient leaves the negative pressure room connected to a SPO2 probe Rationale: The patient should leave the negative pressure room by wearing a surgical mask because otherwise this may cause the pathogens to spread to other individuals. Rationale: The nurse should immediately ensure that the client with suspected or confirmed TB infection has been isolated in a private room with negative air-flow to prevent the spread of pathogens. Rationale: The nurse should don a N95 mask respirator per guidelines of droplet precautions when entering the client's private room. This helps in preventing the spread of the pathogens. Rationale: The visitors when entering the client's private room should wear a snug fitting surgical mask to prevent the spread of pathogens. Test Taking Tips: Reflect on infection protocol.
Which nursing intervention should be considered a priority when caring for a patient with tuberculosis (TB) infection? -Conducting a Mantoux Tuberculin skin test as prescribed -Isolating the patient in a private room with negative airflow -Conducting a chest x-ray per order of the provider -Administering first-line antitubercular medications as prescribed
Isolating the patient in a private room with negative airflow Rationale: Immediate isolation of the patient with TB infection in a private room with negative airflow is considered a priority because the infection can spread easily to other individuals. Rationale: The Mantoux Tuberculin skin test is the standard method for determining if an individual is infected with the TB-causing organism; however, it is important to isolate the patient first. Rationale: A chest x-ray report of a TB-infected patient may show suspicious cavitating lesions. However, it is important to conduct tests only after isolating the patient to prevent the spread of infection. Rationale: First-line antitubercular medications should be administered to the patient who is being treated for TB. However, it is important to minimize the transmission of TB infection to other persons; therefore, the patient must be isolated first. Test Taking Tips: Safety is the priority.
Which is true regarding primary progressive TB infection (PPTBI)? -It may develop in individuals who are exposed to bacterium. -It may mean that the first-line medications used for the treatment of TB will be ineffective. -It is often asymptomatic and is only confirmed by positive sputum cultures and a positive skin test. -It is only when the immune system becomes compromised that the disease can become reactivated.
It may develop in individuals who are exposed to bacterium. Rationale: Symptomatic TB infection is referred to as PPTBI, which may develop in a very small percentage of individuals who are exposed to bacterium. Rationale: In patients who are suffering from multidrug-resistant TB, the first-line medications used for the treatment of the disease will be ineffective. Rationale: Primary TB infection is only confirmed by positive sputum cultures and a positive skin test because it is often asymptomatic. Rationale: In patients with latent TB infection (LTBI), the disease can become reactivated only when the immune system becomes compromised. It can be reactivated due to HIV infection, long-term diabetes, chronic renal disease, long-term steroid administration, sepsis, and malnutrition. Test Taking Tips: Differentiate between the different types of tuberculosis (TB).
Which classification of tuberculosis (TB) infection can be caused by primary or secondary spread? -Multidrug-resistant TB -Latent TB infection -Primary TB infection -Primary progressive TB infection
Multidrug-resistant TB Rationale: Multidrug-resistant TB can be caused by primary or secondary spread. Primary resistance is caused by person-to-person transmission of the resistant organism and secondary TB develops during treatment and results from an ineffective or incomplete treatment regimen. Rationale: Patients with latent TB infection have no symptoms because they do not feel ill and are not contagious. The disease can be reactivated only when Rationale: Primary TB infection is often without any symptoms and is only determined by positive sputum cultures and a positive skin test. Rationale: Primary progressive TB infection shows symptoms such as fatigue, weight loss, and night sweats initially, and as it progresses, a cough develops that produces a rusty-colored or blood-streaked sputum, which also causes dyspnea, orthopnea, etc. Test Taking Tips: Do not confuse different tuberculosis (TB) types.
Which personal protective equipment (PPE) should the nurse don prior to entering the room to assist William after he has vomited? Select all that apply. -Surgical mask -N95 respirator -Head covering -Shoe protectors -Gloves
N95 respirator Gloves An N95 respiratory mask is required prior to entering any client's room who is suspected of having TB. Since the client has vomited, you should also wear gloves. A surgical mask, head covering, and shoe protectors are not required PPE.
William is admitted to the medical-surgical unit. Which action is appropriate when transporting him from the ED to the unit? Wearing an N95 respirator during the transport -Placing a surgical mask on the client for transport -Asking the client to use the steps during transport -Clearing all people from the route used for transport -Check Answer
Placing a surgical mask on the client for transport CORRECT. If a client suspected of having TB must be transported from one area of the hospital to another, it is essential for you to place a surgical mask on the client for the transport. You would not wear an N95 respirator during the transport. It is inappropriate to ask the client to use the steps during the transport. Clearing all people from the route used for transport may not be feasible.
The nurse is assessing a patient who has developed orthopnea and rales. On further investigation, the nurse finds that the patient often coughs up rust-colored sputum. The patient also has night sweats and weight loss. Which kind of tuberculosis (TB) does the nurse expect the patient to be diagnosed with in this situation? -Latent TB infection (LTBI) -Multidrug-resistant TB (MDR TB) -Primary progressive TB infection (PPTBI) -Primary TB infection (PTBI)
Primary progressive TB infection (PPTBI) Rationale: The patient is suffering from PPTBI or symptomatic TB infection. The initial symptoms of the infection are night sweats, weight loss, and fatigue. The patient eventually develops cough that is accompanied by rust-colored, blood-streaked sputum. With the progression of the disease, orthopnea and rales are evident. This kind of TB is less common. Rationale: A patient with LTBI has no symptoms, does not feel ill, and is not contagious. Rationale: Multidrug-resistant TB (MDR TB) can be differentiated into monodrug- or polydrug-resistant. One or more of the first-line medications cannot treat this type of TB. Rationale: Primary TB infection (PTBI) is asymptomatic in nature. This TB infection is confirmed only by positive sputum cultures and a positive skin test. Test Taking Tips: Differentiate the types of tuberculosis (TB).
Which type of precautions should be used when providing care for William? Select all that apply. -Standard precautions -Contact precautions -Droplet precautions -Airborne precautions -Reverse isolation precautions
Standard precautions Airborne precautions A client suspected of having TB will require standard precautions in addition to airborne precautions, a type of isolation precaution. Airborne precautions require placement in an airborne infection isolation room (AIIR) and the use of an N-95 mask. Contact, droplet, and reverse isolation precautions are not required for this client.
The current plan of care includes discharge of William to home once the criteria to decrease the risk of disease transmission have been obtained. Which should the nurse assess to determine if he is likely to have successful adherence to treatment after discharge? -Occupation -Support system -Financial resources -Type of health insurance
Support system CORRECT. In order to determine the client's successful adherence to the treatment plan after discharge, you should assess the client's support system. The client's occupation, financial resources, and type of health insurance are not factors that directly impact adherence to the treatment plan after discharge.
William's family arrives for a visit. Which personal protective equipment (PPE) should the nurse educate the family to wear? -Gown -Gloves -Surgical mask -Shoe protection
Surgical mask CORRECT. A snug-fitting surgical mask is required for all visitors for a client who is isolated for potential TB. A gown, gloves, and shoe protection are not required PPE to enter this client's room.
Which is the main cause of blood tinged, rust-colored sputum in a patient suffering from tuberculosis (TB)? -The destruction of lung parenchyma tissue -The inflammatory process of the lungs -Decreased pH and increased carbon dioxide (CO2) -Tachypnea and tachycardia
The destruction of lung parenchyma tissue Rationale: The destruction of lung parenchyma tissue is the main cause of blood tinged, rust-colored sputum in the patient. Rationale: The inflammatory process of the lungs causes homeostasis in a patient with influenza. Rationale: Respiratory acidosis is indicated by decreased pH and increased CO2 in the patient. Rationale: Tachypnea and tachycardia result from the inflammatory response to bacterial infection. Test Taking Tips: Consider the pathophysiology.
What should the nurse recommend for the client's family members based on the current information? -Annual chest x-rays -Isolation precautions -Tuberculosis skin tests -Prophylactic antibiotics
Tuberculosis skin tests CORRECT. It is important to stress the need for skin testing for all individuals who live with the infected person. Skin testing helps monitor the spread of TB and ensures that prompt treatment is initiated, if necessary. The family also needs to be notified that they'll need to return to have the skin test read in 48-72 hours. Annual chest x-rays are required for individuals who test positive for tuberculosis skin testing. Isolation precautions are not necessary unless a member of the family tests positive for TB. Prophylactic antibiotics are not initiated without knowing the client's TB status.
