Respiratory Saunders
A nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears which of the following items during periods of exposure to silica particles? 1. Mask 2. Gown 3. Gloves 4. Eye protection
ANS: 1. Mask Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. The other options are not necessary.
A client who has been taking isoniazid (INH) for 1½ months complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing: 1. Hypercalcemia 2. Peripheral neuritis 3. Small blood vessel spasm 4. Impaired peripheral circulation
ANS: 2. Peripheral neuritis Rationale: A common side effect of INH is peripheral neuritis. This is manifested by numbness, tingling, and paresthesias in the extremities. This side effect can be minimized with pyridoxine (vitamin B6) intake.
The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Choose the instructions that the nurse will include on the list. Select all that apply. 1. Activities should be resumed gradually. 2. Avoid contact with other individuals, except family members, for at least 6 months. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members have already been exposed. 5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. 6. When one sputum culture is negative, the client is no longer considered infectious and can usually return to his or her former employment.
ANS: 1. Activities should be resumed gradually. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members have already been exposed. 5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. Rationale: The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client is to follow the medication regimen exactly as prescribed and always to have a supply of the medication on hand. The client is advised of the side effects of the medication and ways of minimizing them to ensure compliance. The client is reassured that, after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. The client is also informed that activities should be resumed gradually and about the need for adequate nutrition and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection. The client and family are informed that respiratory isolation is not necessary, because family members have already been exposed. The client is instructed about thorough handwashing and to cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. The client is informed that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated and, when the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to his or her former employment.
A nurse is preparing to suction an adult client through the client's tracheostomy tube. Which intervention(s) would the nurse perform for this procedure? Select all that apply. 1. Apply suction for up to 10 to 15 seconds. 2. Hyperoxygenate the client before suctioning. 3. Set the wall suction unit pressure at 160 mm Hg. 4. Apply suction while gently inserting the catheter. 5. Apply intermittent suction while rotating and withdrawing the catheter. 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm.
ANS: 1. Apply suction for up to 10 to 15 seconds. 2. Hyperoxygenate the client before suctioning. 5. Apply intermittent suction while rotating and withdrawing the catheter. 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm. Rationale: Intermittent suction is applied while rotating the catheter for 10 to 15 seconds. The nurse should hyperoxygenate the client with a resuscitator bag/Ambu-bag connected to an oxygen source before suctioning because suction depletes the client's oxygen supply (option 2). The catheter should be inserted quickly and gently until resistance is met or the client coughs; then pulled back 1 cm or ½ inch. Intermittent suction is applied while rotating and withdrawing the catheter. Option 3 is incorrect because wall suction should be set to 80 to 120 mm Hg. Pressure set at a higher level can cause trauma to respiratory tract tissues. Strict asepsis needs to be maintained, and the nurse would wear sterile gloves to perform this procedure. Suction is never applied when inserting the catheter because it will deplete oxygen and can traumatize tissues.
A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which one of the following would the nurse expect the client to experience? 1. Dyspnea 2. Headache 3. Weight gain 4. Hypothermia
ANS: 1. Dyspnea Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There may be an enlargement of the client's lymph nodes, liver, and spleen as well.
A nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse prepares the client for the procedure, knowing that this type of tube: 1. Enables the client to speak 2. Prevents the client from speaking 3. Is necessary for mechanical ventilation 4. Prevents air from being inhaled through the tracheostomy opening
ANS: 1. Enables the client to speak Rationale: A fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enables the client to speak.
A nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. What equipment would the nurse plan to have at the bedside when the client returns from surgery? 1. Obturator 2. Oral airway 3. Epinephrine 4. Tracheostomy tube with the next larger size
ANS: 1. Obturator Rationale: A replacement tracheostomy tube of the same size and an obturator is kept at the bedside at all times, in case the tracheostomy tube is dislodged. In addition, a curved hemostat that could be used to hold the trachea open, if dislodgment occurs, should also be kept at the bedside. An oral airway and epinephrine would not be needed.
A nurse is assigned to care for a client after a left pneumonectomy. Which one of the follow positions would be contraindicated for this client? 1. On the side 2. In a low Fowler's position 3. In a semi-Fowler's position 4. With the head of the bed elevated 40 degrees
ANS: 1. On the side Rationale: Complete lateral positioning is contraindicated for a client following pneumonectomy. Because the mediastinum is no longer held in place on both sides by lung tissue, lateral positioning may cause mediastinal shift and compression of the remaining lung. The head of the bed should be elevated.
A nurse notes that a hospitalized client has experienced a positive reaction to the Mantoux skin test. Which action by the nurse is the priority? 1. Report the findings. 2. Document the finding in the client's record. 3. Call the employee health service department. 4. Call the radiology department for a chest x-ray.
ANS: 1. Report the findings. Rationale: The nurse who interprets a Mantoux skin test as positive notifies the health care provider (HCP) immediately. The HCP would prescribe a chest x-ray to determine whether the client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture would be done to confirm the diagnosis of active TB. The client is placed on TB precautions prophylactically until a final diagnosis is made. The findings are documented in the client's record, but this action is not the highest priority. Calling the employee health service would be of no benefit to the client.
A nurse is caring for a client with an endotracheal tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse prepares to perform which nursing intervention? 1. Suction the client. 2. Check for a disconnection. 3. Notify the respiratory therapist. 4. Evaluate the tube cuff for a leak.
ANS: 1. Suction the client. Rationale: When the high-pressure alarm sounds on a ventilator, it is most likely caused by an obstruction. The obstruction can be caused by the client biting on the tube, kinking of the tubing, or mucus plugging requiring suctioning. It is also important to check the tubing for the presence of any water and determine whether the client is out of rhythm with breathing with the ventilator. A disconnection or a cuff leak can result in the sounding of the low-pressure alarm. The respiratory therapist would be notified if the nurse could not determine the cause of the alarm.
A nurse is caring for a client with emphysema who is receiving oxygen. The nurse checks the oxygen flow rate to ensure that it does not exceed: 1. 1 L/min 2. 2 L/min 3. 6 L/min 4. 10 L/min
ANS: 2. 2 L/min Rationale: Between 1 and 3 L/min of oxygen by nasal cannula may be required to raise the Pao2 level to 60 to 80 mm Hg. However, oxygen is used cautiously in the client with emphysema and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in this disorder, the respiratory drive is triggered by low oxygen levels rather than by increased carbon dioxide levels, which is the case in a normal respiratory system.
A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect the client to experience? 1. Hypocapnia 2. A hyperinflated chest on x-ray 3. Increased oxygen saturation with exercise 4. A widened diaphragm noted on chest x-ray
ANS: 2. A hyperinflated chest on x-ray Rationale: Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.
A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note in this client? Select all that apply. 1. Hypocapnia 2. Dyspnea on exertion 3. Presence of a productive cough 4. Difficulty breathing while talking 5. Increased oxygen saturation with exercise 6. A shortened expiratory phase of respiration
ANS: 2. Dyspnea on exertion 3. Presence of a productive cough 4. Difficulty breathing while talking Rationale: Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory muscles of respiration, and a prolonged expiratory phase of respiration. The client may also exhibit difficulty breathing while talking, and may have to take breaths between every one or two words. Some clients with COPD, especially those with a history of smoking, often have a productive cough especially on arising in the morning. The chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.
A nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further instruction about its use if the client says she must: 1. Sit upright when using the device. 2. Inhale slowly, maintaining a constant flow. 3. Place the lips completely over the mouthpiece. 4. After maximal inspiration, hold the breath for 10 seconds and then exhale
ANS: 2. Inhale slowly, maintaining a constant flow. Rationale: For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold her breath for 5 seconds and then exhale slowly through pursed lips.
A nurse is reading the results of a Mantoux skin test on a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets that the result is: 1. Positive 2. Negative 3. Uncertain 4. Borderline
ANS: 2. Negative Rationale: A positive Mantoux reading has an induration measuring 10 mm or more in diameter and indicates exposure to tuberculosis. A small area of ecchymosis is insignificant and is probably related to injection technique.
An emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign, if noted in the client, would indicate the presence of a pneumothorax? 1. Bradypnea 2. Shortness of breath 3. A low respiratory rate 4. The presence of a barrel chest
ANS: 2. Shortness of breath Rationale: The client has sustained a blunt or a closed chest injury. This type of injury can result in a closed pneumothorax. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may present with tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. There may also be hyperresonance on the affected side. The presence of a barrel chest is characteristic of chronic obstructive pulmonary disease or emphysema.
A nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, the nurse determines that: 1. There is a leak in the system. 2. The chest tube is functioning as expected. 3. The amount of suction needs to be decreased. 4. The occlusive dressing at the insertion site needs reinforcement.
ANS: 2. The chest tube is functioning as expected. Rationale: The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has re-expanded.
A nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse indicates that the client is performing the technique correctly? 1. The client breathes in through the mouth. 2. The client breathes out slowly through the mouth. 3. The client avoids using the abdominal muscles to breathe out. 4. The client puffs out the cheeks when breathing out through the mouth.
ANS: 2. The client breathes out slowly through the mouth. Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. The client should close the mouth and breathe in through the nose. The client then purses the lips and breathes out slowly through the mouth, without puffing the cheeks. The client should spend at least twice the amount of time breathing out that it took to breathe in. The client should use the abdominal muscles to assist in squeezing out all of the air. The client also is instructed to use this technique during any physical activity, to inhale before beginning the activity, and to exhale while performing the activity. The client should never hold the breath.
The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action will the nurse take? 1. Administer oxygen. 2. Ventilate the client manually. 3. Check the client's vital signs. 4. Start cardiopulmonary resuscitation (CPR).
ANS: 2. Ventilate the client manually. Rationale: If an alarm is sounding at any time and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual resuscitation device is used to support respirations until the problem can be corrected. Although oxygen is helpful, it will not provide ventilation to the client. Checking vital signs is not the initial action. There is no reason to begin CPR.
A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings would the nurse expect to note? Select all that apply. 1. Excessive bubbling in the water-seal chamber 2. Vigorous bubbling in the suction-control chamber 3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation
ANS: 3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation Rationale: The bubbling of water in the water-seal chamber indicates air drainage from the client. This is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water-seal chamber may indicate an air leak, which is an unexpected finding. The fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed, the lung has re-expanded, or no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 to 100 mL/hr is considered excessive and requires health care provider notification. The chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.
A nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection? 1. An uninsured man who is homeless 2. A woman newly immigrated from Korea 3. A man who is an inspector for the U.S. Postal Service 4. An older woman admitted from a long-term care facility
ANS: 3. A man who is an inspector for the U.S. Postal Service Rationale: People at high risk for acquiring tuberculosis include children younger than 5 years of age; homeless individuals or those from a lower socioeconomic group, minority groups, or immigrant group; individuals in constant, frequent contact with an untreated or undiagnosed individual; individuals living in crowded areas, such as long-term care facilities, prisons, and mental health facilities; older clients; individuals with malnutrition, an infection, or an immune dysfunction or human immunodeficiency virus infection, or individuals who are immunosuppressed as a result of medication therapy; and individuals who abuse alcohol or are intravenous drug users.
The nurse is caring for an older client who is on bedrest. The nurse plans which intervention to prevent respiratory complications? 1. Decreasing oral fluid intake 2. Monitoring the vital signs every shift 3. Changing the client's position every 2 hours 4. Instructing the client to bear down every hour and to hold his or her breath
ANS: 3. Changing the client's position every 2 hours Rationale: Frequent position changes help mobilize lung secretions and prevent pooling. This is the only intervention identified in the options that will prevent respiratory complications. The nurse would encourage fluid intake to thin secretions and thus enable the client to expectorate more easily. It is important to encourage coughing and deep breathing to mobilize lung secretions. The nurse should assess the client's vital signs every 4 hours to identify an elevated temperature, which may suggest infection. The client should be instructed to avoid the Valsalva maneuver or any activity that involves holding the breath.
A nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which of the following observations are made? 1. Skin color becomes cyanotic. 2. Secretions are becoming bloody. 3. Coughing occurs with suctioning. 4. Heart rate decreases from 78 to 54 beats/minute.
ANS: 3. Coughing occurs with suctioning. Rationale: Coughing is a normal response to suctioning for the client with an intact cough reflex, and it is not an indication that the client is not tolerating the procedure. The client should be encouraged to cough to help with removal of secretions from the lungs. The nurse should monitor for the adverse effects of suctioning, which include cyanosis (pulse oximetry falls below 90% or 5% from baseline), excessively rapid or slow heart rate (a 20 beat/minute change), or the sudden development of bloody secretions. If they occur, the nurse stops suctioning, administers oxygen as appropriate, and reports these signs to the health care provider immediately.
A nurse has reinforced discharge teaching with a client who was diagnosed with tuberculosis (TB) and has been on medication for 1½ weeks. The nurse knows that the client has understood the information if the client makes which statement? 1. "I can't shop at the mall for the next 6 months." 2. "I need to continue medication therapy for 2 months." 3. "I can return to work if a sputum culture comes back negative." 4. "I should not be contagious after 2 to 3 weeks of medication therapy."
ANS: 4. "I should not be contagious after 2 to 3 weeks of medication therapy." Rationale: The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client is generally considered to be not contagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds, until the medication is effective in preventing transmission. The client is allowed to return to employment when the results of three sputum cultures are negative.
A nurse is collecting subjective and objective assessment data from a client admitted to the hospital with tuberculosis (TB). The nurse should expect to note which of the findings? 1. High fever 2. Flushed skin 3. Complaints of weight gain 4. Complaints of night sweats
ANS: 4. Complaints of night sweats Rationale: The client with TB usually experiences a low-grade fever, weight loss, pallor, chills, and night sweats. The client also will complain of anorexia and fatigue. Pulmonary symptoms include a cough that is productive of a scant amount of mucoid sputum. Purulent, blood-stained sputum is present if cavitation occurs. Dyspnea and chest pain occur late in the disease.
A client is being prepared for a thoracentesis. The nurse assigned to care for the client assists the client to which of the following positions for the procedure? 1. Sims' position with the head of the bed flat 2. Prone with the head turned to the side supported by a pillow 3. Lying in bed on the affected side with the head of the bed elevated 45 degrees 4. Lying in bed on the unaffected side with the head of the bed elevated 45 degrees
ANS: 4. Lying in bed on the unaffected side with the head of the bed elevated 45 degrees Rationale: To facilitate the removal of fluid from the chest, the client is positioned sitting on the edge of the bed, leaning over a bedside table, with the feet supported on a stool or lying in bed on the unaffected side with the head of the bed elevated 45 degrees (Fowler's position).
A nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). The nurse monitors the client for this complication by: 1. Monitoring for pain 2. Monitoring respirations hourly 3. Checking the blood pressure every 2 hours 4. Palpating for the leakage of air into the subcutaneous tissues
ANS: 4. Palpating for the leakage of air into the subcutaneous tissues Rationale: Subcutaneous emphysema is also known as crepitus. It presents as a "puffed-up" appearance that is caused by the leakage of air into the subcutaneous tissues. It is monitored by palpating, and it feels like bubble wrap when palpated. Although options 1, 2, and 3 may be components of the plan of care for a client with a chest tube, these actions will not identify subcutaneous emphysema.
A nurse is assigned to assist the health care provider with the removal of a chest tube. The nurse instructs the client to do which of the following during this process? 1. Stay very still. 2. Exhale forcefully. 3. Inhale and exhale quickly. 4. Perform Valsalva's maneuver.
ANS: 4. Perform Valsalva's maneuver. Rationale: When the chest tube is removed, the client is asked to perform Valsalva's maneuver (i.e., take a deep breath, exhale, and bear down), the tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.
A nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. The nurse tells the client that the primary purpose of pursed lip breathing is to: 1. Promote oxygen intake. 2. Strengthen the diaphragm. 3. Strengthen the intercostal muscles. 4. Promote carbon dioxide elimination.
ANS: 4. Promote carbon dioxide elimination. Rationale: Pursed lip breathing facilitates maximal expiration for clients with obstructive lung disease and promotes carbon dioxide elimination. This type of breathing allows better expiration by increasing airway pressure, which keeps air passages open during exhalation.
A nurse is providing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation? 1. Fever 2. Fatigue 3. Weight loss 4. Shortness of breath
ANS: 4. Shortness of breath Rationale: Shortness of breath is an early sign of exacerbation of pulmonary sarcoidosis. Others include chest pain, hemoptysis, and pneumothorax. Systemic signs and symptoms that occur later include weakness and fatigue, malaise, fever, and weight loss.
A nurse is providing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic periods. Which position will the nurse instruct the client to assume? 1. Sitting up in bed 2. Side-lying in bed 3. Sitting in a recliner chair 4. Sitting on the side of the bed, leaning on an overbed table
ANS: 4. Sitting on the side of the bed, leaning on an overbed table Rationale: Positions that will assist the client with breathing include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, or standing or leaning against the wall.
A nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate? 1. Empty the drainage. 2. Encourage the client to deep breathe. 3. Continue to monitor, because this is an expected finding. 4. Encourage the client to hold his or her breath periodically.
ANS: 3. Continue to monitor, because this is an expected finding. Rationale: The presence of fluctuations in the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. The apparatus and all connections must remain airtight at all times, and the drainage is never emptied. Encouraging the client to deep breathe is unrelated to this observation. The client is not told to hold his or her breath.
A nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. What should the nurse do? 1. Notify the health care provider (HCP) immediately. 2. Finish the suctioning as quickly as possible. 3. Contact the respiratory department to suction the client. 4. Discontinue suctioning until the client is stabilized and monitor vital signs.
ANS: 4. Discontinue suctioning until the client is stabilized and monitor vital signs. RATIONALE: If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. It is also important to monitor the vital signs and the pulse oximetry. If the client's condition continues to deteriorate, then the respiratory department and HCP may need to be notified.
A client being discharged from the hospital to home with a diagnosis of tuberculosis (TB) is worried about the possibility of infecting the family and others. The nurse determines that the client would get the most reassurance from the knowledge that: 1. The family does not need therapy, and the client will not be contagious after 1 month of medication therapy. 2. The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy. 3. The family will receive prophylactic therapy, and the client will not be contagious after 1 continuous week of medication therapy. 4. The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.
ANSWER: 4. The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. Rationale: Family members or others who have been in close contact with a client diagnosed with TB are placed on prophylactic therapy with isoniazid (INH) for 6 to 12 months. The client is usually not contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant TB.
A nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site and next: 1. Replaces the chest tube system 2. Obtains a pulse oximetry reading 3. Notifies the registered nurse (RN) 4. Places the client in Trendelenburg's position
ans: 3. Notifies the registered nurse (RN) Rationale: If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and notifies the RN, who then calls the health care provider (HCP). The nurse would maintain the client in an upright position. A new chest tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry readings would assist in determining the client's respiratory status, but the priority action would be to notify the RN, who will then call the HCP.
