NURS 309 Quiz 8 (Chap 20, 31) RESP 2

169.) A nurse assesses a newly admitted client with a diagnosis of pulmonary tuberculosis (TB). Which clinical findings support this diagnosis? select all that apply. 1. Fatigue 2. Polyphagia 3. Hemoptysis 4. Night sweats 5. Black tongue

1, 3, 4

41.) Which test results indicates a patient has clinically active TB? a. Induration of 12mm and positive sputum b. Positive chest x-ray for TB c. Positive chest x-ray and clinical symptoms d. Sputum tests positive for blood

A

14.) A patient is seen in the health care provider's office and is diagnosed with community-acquired pneumonia. What are the most common symptoms that pt will have? Select all that apply? a. Dyspnea b. Abdominal pain c. Back pain d. Hypoxemia e. Chest discomfort

ADE

15.) Which diagnostic test are most likely to be done for a pt suspected of having community-acquired pneumonia? Select all that apply. a. Sputum gram stain b. Pulmonary function test c. Fluorescein bronchoscopy d. Peak flowmeter measurement e. Chest x-ray

AE

3.) The pt has documented allergy to bananas and avocados. What specific priority precaution must the nurse take when providing care for this patient? Ask the pt about: a. Other food allergies b. Antibiotic drug allergies c. Allergies to pets d. Latex allergies

D

46.) A pt has an HIV infection, but the TB skin test shows an induration of less than 10 mm and no clinical symptoms of TB are present. Which medication does the patient receive for a period of 12 months to prevent TB? a. Bacille Calmette- Guerin (BCG) vaccine b. Isoniazid (INH) c. Ethambutol d. Streptomycin

B

170.) A client who is taking rifampin (Rifadin) tells the nurse, "My urine looks orange." What action should the nurse take? 1. Explain this is expected 2. Check the liver enzymes 3. Strain the urine for stones 4. Ask what foods were eaten

1 Rifampin (Rifadin) causes reddish orange discoloration of secretions such as urine, sweat, and tears.

185.) A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client's anxiety level. 1. Cannula 2. Catheter 3. Venturi mask 4. Rebreather mask

1 Oxygen via nasal cannula is the most comfortable and least intrusive, because the cannula extends minimally into the nose.

18.) When a patient with TB is being prepared for discharge, which statement by the patient indicates a need for further teaching? 1. "Everyone in my family needs to go and see the doctor for TB testing." 2. "I will continue to take my isoniazid until I am feeling completely well." 3. "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag." 4. "I will change my diet to include more foods rich in iron, protein, and vitamin C."

2

180.) A nurse must administer streptomycin 1 g IM to a client with tuberculosis. The vial contains 500 mg/mL. How much solution must the nurse administer? Record your answer using a whole number answer_______mL

2 mL. First convert 1 g to its equivalent of 1000 mg and then use the "Desire over Have" formula of ratio and proportion to solve the problem. Desire 1000mg = x mL ________________________________ Have 500 mg 1 mL 500x = 1000 x= 1000/ 500 x= 2 mL

168.) An older adult, who alternately lives in a homeless shelter on the street, is brought to the emergency department by friends. The client has a fever, night sweats, and a blood-tinged productive cough. The health care provider suspects that the client has tuberculosis and orders purified protein derivate (PPD) test, chest x-ray, and sputum culture. Place these interventions in the order that they should be performed. 1. Obtain a sputum specimen. 2. Institute airborne precautions. 3. Have a chest x-ray performed. 4. Notify the Department of Health. 5. Perform a PPD intradermal skin test.

2, 3, 5, 1, 4

16.) You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to the UAP? 1. Teaching the patient about the importance of adequate fluid intake and hydration. 2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed 3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake 4. Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession

3

183.) A nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi mask. What should the nurse do when caring for this client? 1. Assess frequently for nasal drying 2. Keep the mask tight against the face 3. Monitor oxygen saturation levels when eating. 4. Set the oxygen flow at the highest setting possible.

3 Because the mask cannot be worn when eating, the client may become hypoxic. A nasal cannula may be needed to deliver oxygen while the client is eating.

167.) A client who is to be admitted for minor surgery has a chest radiograph as part of the presurgical physical. The nurse is notified that the radiograph reveals that the client has pulmonary tuberculosis. What evidence of tuberculosis is provided by the radiograph? 1. Sensitized T cells 2. Presence of acid-fast bacilli 3. Cavities caused by caseation 4. Microscopic primary infection

3 Cavities are evident on radiograph. Necrotic lung tissue may liquefy, leaving a cavity (cavitation), or granulose tissue can surround the lesion, become fibrous, and form a collagenous scar around the tubercle (Ghon tubercle).

171.) What must the nurse determine before discontinuing airborne precautions for a client with pulmonary tuberculosis? 1. Client no longer is infected 2. Tuberculin skin test is negative 3. Sputum is free of acid-fast bacteria 4. Client's temperature has returned to normal

3 The absence of bacteria in the sputum indicates that the disease can no longer be spread by the airborne routine.

179.) The nurse should refer a client to the pulmonary clinic for suspected tuberculosis based on which clinical indicators reported during the initial client interview? Select all the apply. 1. Vomiting 2. Chest pain 3. Hemoptysis 4. Night Sweats 5. Bilateral crackles

3, 4

790.) Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active TB. What statements by the client indicate that there is a need for further teaching? select all that apply. 1. "I plan to start taking vitamin B6 with breakfast." 2. "I'll still be taking this drug six months from now." 3. "I sometimes allow our children to sleep in our bed at night." 4. "I know I also have tuberculosis because the skin test was positive." 5. "I'll be skipping the wine but enjoying the cheese at my neighbor's party."

3, 4, 5

184.) A nurse is caring for a client with a Venturi mask who is receiving 40 % oxygen. What nursing actions are indicated? select all that apply. 1. Keep the oxygen source higher than the client's airway. 2. Adjust the liter flow according to the oxygen saturation. 3. Prevent the client's blanket from covering the adaptor's orifices. 4. Ensure that the bag does not deflate completely during inspiration. 5. Check that the appropriate adaptor to deliver the prescribed Fio2 its attached to the mask.

3, 5

26.) The nurse has identified the priority patient problem of ineffective airway clearance with bronchospasms for a patient with pneumonia. The pt has no previous history of chronic respiratory disorders. The nurse obtains an order for which nursing intervention? a. Increased liters of humidified oxygen via facemask b. Scheduled and prn aerosol nebulizer bronchodilator treatments c. Handheld bronchodilator inhaler as needed d. Corticosteroid via inhaler or IV to reduce inflammation

B

23. The HCP is notified of Raymond's physical exam findings indicating possible dehydration and vital signs, including BP of 100/50. It is determined Raymond could use a bolus of IV fluids. HCP prescribes 1000 mL of normal saline to run over 6 hours. Drop factor is 15 drops/mL. How many gtt/min will the IV run? (round to whole number)

42

14. What is the priority nursing diagnosis for Raymond at this time? A. Risk for new opportunistic infections related to decreased immune function B. Social isolation related to worsening of condition C. Imbalanced nutrition, less than body requirements related to medication side effects D. Fatigue related to altered body chemistry

A

17.) A pt is diagnosed with pneumonia. During auscultation of the lower lung fields, the nurse hears coarse crackles and identifies the pt problem of impaired oxygenation. What is the underlying physiologic condition associated with the pt's condition? a. Hypoxemia b. Hyperemia c. Hypocapnia d. Hypercapnia

A

19.) A pt is admitted to the hospital with pneumonia. What does the nurse expect the chest x-ray results to reveal? a. Patchy areas of increased density b. Tension pneumothorax c. Thick secretions causing airway obstruction d. Large hyperinflated airways

A

21.) The nurse is conducting an in-service for the hospital staff about practices that help prevent pneumonia among at-risk patients. Which nursing interventions is encouraged as standard practice? a. Administering vaccines to patients at risk b. Implementing isolations for debilitated patients c. Restricting foods from home in immunosuppressed patients d. Decontaminating respiratory therapy equipment weekly

A

28.) The nurse is providing discharge instructions about pneumonia to a patient and family which discharge information must the nurse be sure to include? a. Complete antibiotics as prescribed, rest, drink fluids, and minimize contact with crowds b. Take all antibiotics as ordered, resume diet and all activities as before hospitalization c. No restrictions regarding activates, diet, and rest because the patient is fully recovered when discharged d. Continue antibiotics only until no further signs of pneumonia are present avoid exposing immunosuppressed individuals

A

29.) A pt is admitted to the hospital with cough, purulent sputum production, temperature of 37.9 C (100.3 F), and reports of shortness of breath. Which intervention does the nurse provide first? a. Set up oxygen equipment and administer oxygen b. Instruct the patient about the importance of keeping the oxygen delivery device on. c. Monitor the effectiveness of oxygen therapy (pulse oximetry, ABG's) as appropriate d. Monitor the patient's anxiety related to the need for oxygen delivery

A

31.) Which complications of pneumonia creates pain that increased on inspiration because of inflammation of the parietal pleura? a. Pleuritic chest pain b. Pulmonary emboli c. Pleural effusion d. Meningitis

A

4. The nurse notices the UAP about to enter Raymond's room to deliver a meal tray without wearing any protective apparel. What information should the nurse provide to the UAP? A. A mask is required for healthcare workers entering the room of someone suspected of having active TB B. Wearing a mask, gown, and gloves is required for healthcare workers entering Raymond's room for any reason C. The UAP will only be in the room for a brief moment to deliver the tray so no intervention is needed by the nurse D. Non-sterile gloves are necessary to deliver the meal and prevent the spread of TB

A

47.) The nurse is teaching a pt about the combination drug therapy that is used in the treatment of TB. Which patient statement indicated the nurse's instruction was effective? a. I will take three drugs; isoniazid, rifampin, and pyrazinamide, then ethambutol may be added later b. Combining the drugs in one pill is a convenient way for me to take all the medications c. The isoniazid combines with TB bacteria. I can take the rifampin and pyrazinamide if I continue to have symptoms d. Combining the medications means to take the isoniazid, rifampin, and pyrazinamide all at the same time

A

20. Raymond develops severe diarrhea with occasional incontinence that could be caused by an opportunistic gastrointestinal infection or by one of his meds. While stool cultures are pending, other interventions can be initiated. Which tasks can be delegated to the UAP? (select all that apply) A. weigh Raymond each morning before breakfast B. Measure urine output C. Count and record number of watery stools D. assess Raymond's peri-rectal skin during incontinent care E. Check Raymond's skin turgor to determine if he is dehydrated

A, B, C

13. Raymond's HCP has also prescribes the anti-TB regiment of rifabutin/isoniazid/pyrazinamide/ethambutol. What information is important to teach Raymond about the use of rifabutin/isoniazid/pyrazinamide/ethambutol? (select all that apply) A. Rifabutin stains urine, stool, saliva, sweat, and tears reddish-orange B. Liver function tests should be routinely conducted and monitored C. There is no need to wear sunscreen when exposed to sunlight while taking rifabutin/isoniazid/pyrazinamide D. Visual disturbances related to ethambutol therapy may develop during therapy, but may resolve once treatment is discontinued E. Rifampin/isoniazid/pyrazinamide has been known to cure HIV within a few months of taking it

A, B, D

5. An acid-fast bacilli (AFB) stain is part of the initial admission prescriptions. Early morning sputum specimens will be collected for 3 consecutive days and sent to the lab. Which tasks may the nurse delegate to the UAP? (Select all that apply) A. have UAP tell Raymond that the specimen must be collected in the early morning B. Provide Raymond with three sterile specimen cups at his bedside. C. Allow the UAP to teach the client how to cough to obtain sputum from deep in the bronchi D. Document the time and date that each sputum specimen was collected E. Instruct the UAP to assess Raymond's ability to expectorate the sputum specimen

A, B, D

18. To achieve the goal of improving Raymond's nutrition, the nurse should perform which nursing intervention? (select all that apply) A. request a dietary consultation for Raymond to better assess Raymond's nutritional status and food preferences B. Request a prescription for total parenteral nutrition C. Monitor for oral thrush and diarrhea D. Instruct Raymond to focus on breakfast, the most important meal of the day E. Weigh daily and record signs of wasting syndrome

A, C, E

9. The nurse creates a plan of care for Raymond. The nursing diagnosis of Knowledge Deficit is used to describe what is needed during client education sessions with Raymond. Which statements by Raymond indicates he understands why he is at risk for TB? (select all that apply) A. "I realize my helper T cells are diminished from HIV. Those are the cells needed to fight TB" B. "I may get TB because my viral load count is diminished" C. "I am at risk for developing TB because I was born with a low number of helper T cells" D. "I realize I am at risk for acquiring TB because I used intravenous drugs in the past" E. "I guess living in that homeless shelter increased my chances of getting TB"

A, E

3. The UAP asks why Raymond could not be in an empty semiprivate room closer to the nurse's station so the staff would not have to walk so far to provide care. What information should the nurse provide to the UAP on infection control practices? A. The client needs to be at the end of the hall because he requires privacy B. The implementation of airborne precautions for possibly TB requires a private, negative pressure room assignment C. A private room is required to implement contact precautions for possible TB D. The client needs to be at the end of the hall for confidentiality

B

30.) A pt has been treated for pneumonia and the nurse is preparing discharge instructions. The pt is capable of performing self-care and is anxious to return to his job at the construction site. Which instructions does the nurse give to this patient? a. You are not contagious to others, so you can return to work as soon as you like b. You will continue to feel tired and will fatigue easily for the next several weeks c. Try and drink 4 quarts of water per day especially if you are very physically active d. You should be able to return to work full-time in 2 weeks when your energy returns

B

10.) The nurse is giving discharge instructions to an adult patient diagnosed with the flu. The patient says, I am generally pretty healthy, but I am concerned because my wife has several serious chronic health problems. What can I do to protect her from getting my flu? What does the nurse instruct the patient to do? Select all that apply a. Wash hands thoroughly after sneezing, cough, or blowing nose b. Avoid kissing, hugging, close face-to-face proximity, or hand-holding c. If there is no tissue immediately available, cough of sneeze into upper sleeve d. Have the wife wear a respiratory filter mask until coughing stops e. Use disposable tissues rather than cloth handkerchiefs, and immediately dispose of tissues

ABCE

49.) The pt is receiving isoniazid (INH) to treat TB. Which nursing intervention points are essential when giving this drug? Select all that apply. a. Teach the patient not to take medications such as Maalox with this medication b. Avoid drinking alcoholic beverages c. Teach the patient that urine will be orange in color d. Take a multivitamin with B complex e. If going out in the sun, be sure to wear protective clothing and sunscreen f. Teach women that this drug reduces the effectiveness of oral contraceptives

ABD

32.) Which conditions may cause patients to be at risk for aspirations pneumonia? Select all that apply. a. Continuous tube feedings b. Bronchoscopy procedure c. Magnetic resonance imaging (MRI) procedure d. Decreased level of consciousness e. Stroke f. Chest tube

ABDE

33.) An older adult pt often coughs and chokes while eating or trying to take medication. The pt insists that he is okay, but the nurse identifies the priority patient problem of risk for aspiration. Which nursing interventions are used to prevent aspiration pneumonia? Select all that apply. a. Head of the bed should always be elevated during feeding b. Monitor the patient's ability to swallow small bites c. Give thin liquids to drink in small, frequent amounts d. Consult a nutritionist and obtain swallow studies e. Monitor the patient's ability to swallow saliva f. Place the patient on NPO status until swallowing is normal

ABDE

The nurse is preparing a teaching plan for the pt and family on how to care for an automatic epinephrine injector? Which essential points must the nurse include? Select all that apply? a. Keep the device with you at all timed b. You can inject the drug right through you pants c. Whenever you use the device, call your doctor and rest in bed for the next 24 to 48 hours d. Protect the device from light and avoid temperature extremes e. Keep safety cap in place until you are ready to use the device

ABDE

1.) For a pt who is having an anaphylactic reaction, which common symptoms will manifest almost immediately after being exposed to an allergen? Select all that apply. a. Angioedema b. Apprehension c. Chills d. Fever e. Urticarial

ABE

2.) A pt in anaphylaxis who is going into respiratory failure will demonstrate which symptoms? Select all that apply? a. Laryngeal edema b. Hypoxemia c. Hypocapnia d. Dehydration e. Crackles f. Wheezing

ABEF

39.) Which people are at greatest risk for developing TB in the US? Select all that apply a. An alcoholic homeless man who occasionally stays in a shelter b. A college student sharing a room in the dormitory c. A person with immune dysfunction or HIV d. A homemaker who does volunteer work at a homeless shelter e. Foreign immigrants (especially from the Philippines and Mexico)

ACE

40.) After several weeks of "not feeling well", a pt is seen in the provider's office for possible TB. If TB is present, which assessment findings does the nurse expect to observe? Select all that apply. a. Fatigue b. Weight gain c. Night sweats d. Chest soreness e. Low-grade level

ACE

6.) Which pt are at risk for developing health-care acquired pneumonia Select all that apply a. Confused patient b. Patient with atrial fibrillation who is alert and oriented c. Patient with gram-negative colonization of the mouth d. Patient with hyperthyroidism e. Malnourished patient

ACE

34.) Which condition causes a pt to have the greatest risk for community-acquired pneumonia? a. Tube feedings b. History of tobacco use c. Poor nutritional status d. Altered mental status

B

2. Raymond's significant other arrives. Raymond wants to know why a mask is necessary for people entering his room. What teaching should the nurse implement? A. explain use of private room and mobile high-efficiency particle filters placed in the room B. explain that the TB organism is most often spread through the air C. tell Raymond that TB will not spread to others and everything will be okay if the mask is worn D. tell Raymond that masks are required for those persons who do not agree to be vaccinated with BCG vaccine.

B

12.) Which pt is at highest risk for developing pneumonia? a. Any hospitalized pt between the ages of 18-65 years old b. 32-yeard-old patient on a mechanical ventilator c. disabled 54-years-old with osteoporosis; discharged to home d. any patient who had not received the vaccine for pneumonia

B

13.) Which statement best described pneumonia? a. An infection of just the "windpipe" because the lungs are "clear" of any problems b. A serious inflammation of the bronchioles from various causes c. Only an infection of the lungs with mild to severe effects on breathing d. An inflammation resulting from lung damage by long-term smoking

B

19. Since Raymond now has thrush, in addition to fatigue and anorexia, which food best contributes to improving Raymond's nutrition? A. Broiled steak B. milk shake C. tomato soup D. lettuce salad with raw vegetables

B

48.) A pt diagnosed with TB has been receiving treatment for 3 weeks and had clinically shown improvement. The family asks the nurse if the pt is still infectious. What is the nurse's reply? a. The patient is still infectious until the entire treatment is completed b. The patient is not infectious but needs to continue treatment for at least 6 months c. The patient is infectious until there is a negative chest x-ray d. The patient may or may not be infectious; a purified protein derivative test (PPD) must be done

B

50.) A pt with suspected TB is admitted to the hospital. Along with private room, which nursing intervention is appropriate related to isolation procedures? a. Respiratory isolation and contact isolation for sputum only b. Strict respiratory isolation and use specifically designed facemasks c. Respiratory isolation with surgical masks until diagnoses is confirmed d. No respiratory isolation necessary until diagnosis is confirmed

B

54.) The nurse is making home visits to an older adult recovering from a hip fracture and identifies the priority patient problem of risk of respiratory infection. Which condition represents a factor of normal aging that would contribute to this increased risk? a. Inability to force a cough b. Decreased strength of respiratory muscles c. Increased elastic recoil of alveoli d. Increased macrophages in alveoli

B

6. Raymond is scheduled for several activities the following morning. What activity should Raymond perform first upon wakening? A. Eat nutritionally dense, early morning snack sent from food services department B. Obtain the first of three sputum specimens for laboratory testing C. Take a shower and get ready to go to radiology for a chest X-ray. D. Weigh to determine if weight loss from the disease is continuing

B

After 3 days, nurse receives results from Raymond's TB skin test that was administered at his HCP's office. Even though Raymond's reaction to the TB test measures only 5mm in diameter, the HCP documents a positive test result. A new graduate nurse finds this confusing. New grad thought that a 10mm induration was the minimum size for a positive reading and asks the nurse preceptor for clarification. How should the nurse preceptor respond? A. "This confuses me too. I think we need to consult with the HCP" B. "That is not always true. A 5mm induration is considered positive for TB in a person with HIV" C. "It may be that you are confusing induration with inflammation in skin testing results" D. "Let's ask the nurse practitioner who specializes in caring for clients who are HIV positive"

B

20.) What nursing intervention may help to prevent the complication of pneumonia for a surgical patient? a. Monitoring chest x-rays and WBC counts for early signs of infection b. Monitoring lung sounds every shift and encouraging fluids c. Teaching coughing, deep-breathing exercising, and use of incentive spirometer d. Encouraging hand hygiene among all care-givers, patients, and visitors

C

38.) Which statements about the precautions of caring for a hospitalized patient with TB are true? Select all that apply. a. Health care workers must wear a mask that covers the face and mouth b. Negative airflow rooms are required for these patients c. Health care workers must wear an N95 or high efficiency particulate air (HEPA) mask d. Gown and gloves are included in appropriate barrier protection e. Strict contact precautions must be maintained

BCD

8.) A patient with COPD needs instruction in measures to prevent pneumonia. What information does the nurse include? Select all that apply a. Avoid going outside b. Clean all respiratory equipment you have at home c. Avoid indoor pollutants such as dust and aerosols d. Get plenty of rest and sleep daily e. Limit alcoholic beverages to 4-5 per week

BCD

36.) The nurse is preparing a community information pack about "bird flu". What information does the nurse include for public dissemination? Select all that apply. a. In the event of an outbreak, do not eat any cooked or uncooked poultry products b. Prepare a minimum of 2 weeks supply of food, water, and routine prescription drugs c. Listen to public health announcements and early warning signs for disease outbreaks d. Avoid traveling to areas where there has been a suspected outbreak of disease e. Obtain a supply of antivirals drugs such as oseltamivir (Tamiflu) f. In the event of an outbreak, avoid going to public areas such as churched and schools

BCDF

53.) Pt who are at high risk for TB would be asked which questions upon assessment? Select all that apply. a. What does your diet normally consist of? b. Do you have an immune dysfunction or HIV c. Do you use alcohol or inject recreational drugs? d. Do you live in the United States? e. Do you work in a crowded area such as a prison or mental health facility?

BCE

1. Nurse admits Raymond to private room. Nurse puts on mask before admission process. Raymond tells the nurse that his significant other is downstairs and he would like for him to stay in the room with him. How should the nurse respond? A. "your HCP wants you to get some rest" B. "he may stay, but only after we have the results of his tuberculin skin test" C. "He may stay, but he needs to wear a mask" D. "you dont want to risk infecting your significant other with TB, do you?"

C

11.) The pt developed flu symptoms less than 24 hours ago. Which drug therapy does the nurse expect the health care provider to order at this time? a. Penicillin therapy b. Amantadine (Symmetrel) c. Oseltamivir (Tamiflu) d. IV steroid therapy

C

17. What instruction should the nurse give Raymond about the use of liquid nystatin (Nyamyc)? A. place all of the suspension in the mouth, then swish and swallow immediately B. sip the suspension over 5 minutes, swishing and swallowing after each sip C. place the suspension in the mouth, then swish for several minutes before swallowing D. use the applicator to paint the medication on the infected sites and swallow the remaining dose

C

18.) Which pt is the least likely to be at risk for developing pneumonia? a. Patient with a 5-year history of smoking b. Renal transplant patient c. Postoperative patient with a beside commode d. Postoperative patient with a hip replacement

C

21. When performing morning physical assessment, nurse discovers he has weak, rapid pulse, decreased skin turgor, and dry, sticky, oral mucous membranes. Weight is 2 lbs (0.91 kg) less than yesterday. What is highest priority nursing diagnosis for Raymond? A. fatigue B. disturbed sleep pattern C. deficit fluid volume D. situational low self-esteem

C

22. Which action should the nurse take first? A. hold Raymond's breakfast tray to provide bowel rest. B. perform oral care and moisten mucous membranes C. take Raymond's BP to assess for postural hypotension D. notify HCP of Raymond's weak, rapid pulse

C

22.) A pt hospitalized for pneumonia has the priority patient problem of ineffective airway clearance related to fatigue, chest pain, excessive secretions, and muscle weakness. What nursing intervention helps to correct this problem? a. Administer oxygen to prevent hypoxemia and atelectasis b. Push fluids to greater than 3000mL/day to ensure adequate hydration c. Administer bronchodilator therapy in a timely manner to decrease bronchospasms d. Maintain semi-fowlers position to facilitate breathing and prevent further fatigue

C

23.) A pt is admitted to the hospital for treatment of pneumonia. Which nursing assessment finding best indicates that the patient is responding to antibiotics? a. Wheezing, oxygen at 2 L/min, respiratory rate 26, no shortness of breath or chills b. Temperature 99 F, lung sounds clear, pulse oximetry on 2 L/min at 98%, cough with yellow sputum c. Cough, clear sputum, temperature 99 F, pulse oximetry at 96% on room air d. Feeling tired, respiratory rate at 28 on 2 L/min of oxygen, audible breath sounds

C

27.) An older adult patient asks the nurse how often one should receive the pneumococcal vaccine for pneumonia prevention. What is the nurse's best response a. Every year when the patient is receiving the "flu shot" b. The standard is vaccination every 3 years c. It is usually given once, but some older adults may need a second vaccination after 5 years d. There is no set schedule; it depends on the patient's history and risk factors

C

35.) In the event of new severe acute respiratory syndrome (SARS) outbreak, what is the nurse's primary role? a. Immediately report new cases of SARS to the Centers for Disease Control and Prevention (CDC) b. Administer oxygen, standard antibiotics, and supportive therapies to patients c. Prevent the spread of infection to other employees and patients d. Initiate and strictly enforce contact isolation procedures

C

37.) A pt reports experiencing mild fatigue and a dry, harsh cough, there is a possibility of exposure to inhalation anthrax, but the pt currently reports feeling much better. What does the nurse advise the patient to do? a. Have a complete blood count to rule out the disease b. Monitor for and immediately seek attention for respiratory symptoms c. Consult a provider for diagnostic testing and antibiotic therapy

C

4.) The nurse is caring for a pt and suspects anaphylaxis. What first priority action does the nurse take at this time? a. Place the pt on a cardiac monitor b. Insert a large-bore IV line c. Call the rapid response team d. Apply oxygen by nasal cannula

C

43.) A pt has a positive skin test result for TB. What explanation does the nurse give to the patient? a. There is active disease, but you are not yet infectious to others b. There is active disease and you need immediate treatment c. You have been infected but this does not mean active disease is present d. A repeat skin test is necessary because the test could give a false positive result

C

51.) A pt is admitted to the hospital to rule out TB. What type of mask does the nurse wear when caring for this patient? a. Surgical facemask b. Surgical facemask with eye shield c. HEPA respirator mask d. Any type of mask that covers the nose and mouth

C

52.) After being discharged from the hospital, a patient is diagnosed with TB at the outpatient clinic. What is the correct procedure regarding public health policy in this case? a. Contact the infection control nurse at the hospital because the hospital is responsible for the follow-up of this case b. There are no regulations because the patient was diagnosed at the clinic and not during the hospitalization c. Contact the public health nurse so that all individuals who have came in contact with the patient can be screened d. Have the patient sign a waiver regarding the hospital and clinic's liability for treatment

C

7.) A 35-year-old male pt with no health problem states that he had a flu shot last year and asks if it is necessary to have it again this year. What is the best response by the nurse? a. No, because once you get a flu shot, it lats for several years. b. Yes, because the immunity against the virus wears off, increasing your chances of getting the flu c. Yes, because the vaccine guards against a specific virus and reduces your chances of acquiring flu and is only effective for one year d. No, flu shots are only for high-risk patients and you are not considered to be high risk

C

9.) In a long-term care facility for older adults and immunocompromised patients, one employee and several patients have been diagnosed with influenza. What does the supervising nurse do to decrease risk of infection to other patient? a. Ask employees who have flu to stay at home for at least 24 hours b. Place any patients with a sore throat, cough, and rhinorrhea into isolation for 1 to 2 weeks c. Ask employees with flu symptoms to stay at home for up to 5 days after onset of symptoms d. Recommend that all patients and employees be immediately vaccinated for flu

C

25.) A patient is admitted to the hospital to rule out pneumonia. Which infection control technique does the nurse maintain? a. Strict respiratory isolation and use of a specially designated facemask b. respiratory isolation and contact isolation for sputum c. respiratory isolation with a stock surgical mask d. standard precautions and no respiratory isolation

D

16. Which assessment finding by the nurse would be indicative of oral candidiasis, a common secondary infection in persons with compromised immune systems? A. blisters on tongue or oral mucosa B. inflammation of gums C. painless white lesions on lateral surface of the tongue D. white-yellow patches on the tongue or oral mucosa

D

16.) The nurse is reviewing laboratory results for a patient who has pneumonia. Which laboratory value does the nurse expect to see for this patient? a. Decreased hemoglobin b. Increased red blood cells c. Decreased neutrophils d. Increased white blood cells

D

24.) The nurse is reviewing the laboratory results for an older adult patient with pneumonia. Which laboratory value frequently seen in patient with pneumonia may not be seen in this patient? a. RBC 4.0 to 5.0 b. HgB 12 to 16 c. Hct 36 to 48 d. WBC 12 to 18

D

42.) After receiving the subcutaneous Mantoux skin test, a pt with no risk factors returnd to the clinic in required 48 to 72 hours for the test results. Which assessment finding indicted a positive test result? a. Test are is red, warm, and tender to touch b. Induration or a hard nodule of any size at the site c. Infuration/hardened area measures 5 mm or greater d. Induration/hardened area measures 10 mm or greater

D

44.) A pt has been compliant with drug therapy for TB and had returned as instructed for follow-up. Which results indicates that the patient is no longer infections/communicable? a. Negative chest x-ray b. No clinical symptoms c. Negative skin test d. Three negative sputum cultures

D

45.) A pt diagnosed with TB agrees to take the medication as instructed and to complete the therapy. When does the nurse tell the pt is the best time to take the medication? a. Before breakfast b. After breakfast c. Midday d. Bedtime

D