Chapter 31 Test Bank

The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met?

Antibiotics started before admission

A client has been hospitalized with tuberculosis (TB). The clients spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best?

Ask the spouse to explain the fear of visiting in further detail.

A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate?

Assess the client for pain when swallowing.

A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.)

Assisting with chest tube insertion Facilitating pleural fluid sampling Performing frequent respiratory assessment Providing antipyretics as needed

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best?

Older people often have vague symptoms, so an x-ray is essential.

A client has the diagnosis of valley fever accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on?

Oral fluconazole (Diflucan)

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)?

Provide oral care every 4 hours.

Which teaching point is most important for the client with bacterial pharyngitis?

Take all antibiotics as directed.

A client is in the family practice clinic reporting a severe cold that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best?

Teach the client to sneeze in the upper sleeve.

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful?

Try warm, moist heat packs on your face.

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate?

Visiting Nurses for directly observed therapy

A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important?

What is your occupation?

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority?

Educating the client on adherence to the treatment regimen

A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately?

Alanine aminotransferase (ALT): 180 U/L

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.)

22-year-old client with asthma Client with well-controlled diabetes Healthy 72-year-old client Client who is taking medication for hypertension

A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.)

Amoxicillin (Amoxil) Ciprofloxacin (Cipro) Doxycycline (Vibramycin)

A nurse admits a client from the emergency department. Client data are listed below: History - 70 years of age, History of diabetes, On insulin twice a day, Reports new-onset dyspnea and productive cough Physical Assessment - Crackles and rhonchi heard throughout the lungs, Dullness to percussion LLL, Afebrile, Oriented to person only Laboratory Values - WBC: 5,200/mm3, PaO2 on room air 65 mm Hg What action by the nurse is the priority?

Administer oxygen at 4 liters per nasal cannula.

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying I have been drinking tons of water. How am I dehydrated? What response by the nurse is best?

Breathing so quickly can be dehydrating.

The charge nurse on a medical unit is preparing to admit several clients who have possible pandemic flu during a preparedness drill. What action by the nurse is best?

Cohort the clients in the same area of the unit.

A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate?

Facilitate polymerase chain reaction testing.

A nurse working in a geriatric clinic sees clients with cold symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms?

Fexofenadine (Allegra)

A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective?

I will take this medication on an empty stomach.

A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a few days ago and shows the nurse the results of what the client calls an allergy test, as shown below: What action by the nurse takes priority?

Immediately place the client on Airborne Precautions.

A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best?

Inform the client that antibiotics will be needed for 60 days.

A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.)

International normalized ratio (INR): 6.3 Prothrombin time: 35 seconds