Quiz 4

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A 25 year old who had endoscopic sinus surgery 8 hours ago. A 45 year old with a peritonsillar abscess who can no longer swallow. A 55 year old with tuberculosis who is standard first-line therapy. A 65 year old with rhinosinusitis and a fever of 102° F (38.9° C)

A 45 year old with a peritonsillar abscess who can no longer swallow.

Which client will the nurse recognize as being at risk for bacterial sinusitis? A 25 year old with seasonal pollen allergies A 35 year old with a 20-pack-year smoking history who now vapes A 45 year old with multiple dental caries and infected gums A 65 year old who has a poor gag reflex after a stroke

A 45 year old with multiple dental caries and infected gums

A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply. A. Blurry vision B. Constipation C. Difficulty sleeping D. Nausea when drinking beer E. Red-tinged urine F. Sunburn with minimal sun exposure G. Yellowing of the sclera

A. Blurry vision G. Yellowing of the sclera

Which symptom will the nurse expect as typical in an 82-year-old client with pneumonia? Acute confusion Profound bradycardia Coughing spasms High fever

Acute confusion

Which action will the nurse take first when caring for a client with pneumonia who has ineffective airway clearance related to fatigue, chest pain, excessive secretions, and muscle weakness? Administer oxygen to prevent hypoxemia and atelectasis. Administer the prescribed bronchodilator therapy to decrease bronchospasms. Encourage oral fluids to greater than 3000 mL/day to ensure adequate hydration. Maintain semi-Fowler position to facilitate breathing and prevent further fatigue.

Administer the prescribed bronchodilator therapy to decrease bronchospasms.

Which action will the nurse take to ensure that a client who requires drug therapy for multi-drug resistant tuberculosis and also is addicted to heroin adheres to the treatment regimen? Arranging for a health care worker to directly observe the client take the drugs Giving the client written instructions about how and when to take the drugs Instructing the client about the consequences of not taking the drugs Having the client repeat the drug names and side effects

Arranging for a health care worker to directly observe the client take the drugs

A nurse interviewing an 82-year-old somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an influenza vaccination today. The daughter replies "she had one 2 years ago and doesn't need another." What is the nurse's best response? A. "Your mother is older now and is more fragile, so she should have one this year too as a booster." B. "The virus causing influenza often changes each year and a new influenza vaccination is needed every flu season." C. "The "flu shot" she had 2 years ago will still protect her this year but if she has not had a previous pneumonia vaccination, she should have one now." D. "If you are worried that she is afraid to have an injection, we could use the nasal mist vaccination this year."

B. "The virus causing influenza often changes each year and a new influenza vaccination is needed every flu season."

Which adults are at higher risk for development of active tuberculosis? Select all that apply. A. A, 21-year-old college student living in a dorm at a Canadian university B. 38-year-old with AIDS who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years F. 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)

B. 38-year-old with AIDS who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years

A nurse assessing an older adult client with pneumonia notes the client is now confused and the oxygen saturation has dropped since the last assessment 1 hour ago from 90% to 84%. The nurse also notes the respiratory rate has increased from 26 to 32. What is the nurse's best first action? A. Encourage the client to use the incentive spirometer hourly. B. Increase her O2 flow rate by 2 L and re-assess in 5 minutes. C. Increase the flow rate of the IV antibiotic. D. Document the changes as the only action.

B. Increase her O2 flow rate by 2 L and re-assess in 5 minutes.

A nursing home client who has completed a 2 week course of antibiotics for bacterial pneumonia asks whether he can go out to a restaurant to celebrate his grandson's high school graduation if he uses a wheel chair. What is the nurse's best response? A. "No, going out now before you have recovered your strength can cause a relapse of the pneumonia." B. "No, the risk that you could spread this disease to other people is much too high." C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting." D. "Yes, if you agree to wear a face mask to prevent spreading droplets."

C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting."

The spouse of a 78-year-old client who was discharged to home 1 day ago after hospitalization for seasonal influenza calls to report the fever has returned and is now 103.4 degrees F (39.7 degrees C). What is the nurse's primary concern for this client? A. The client may not be taking the prescribed antiviral drug correctly B. A second strain of influenza is likely C. Pneumonia may be present D. The client may be dehydrated

C. Pneumonia may be present

Development of which symptoms indicates to the nurse that a 48-year-old client with seasonal influenza may actually have COVID-19? Anorexia and weight loss Intermittent fever and sweating Chest tightness and SpO2 of 86% Productive cough and yellow-colored sputum

Chest tightness and SpO2 of 86%

Which drug will the nurse expect to teach about to a client who has been exposed to inhalation anthrax but does not have symptoms? Rifampin Oseltamivir Vancomycin Ciprofloxacin

Ciprofloxacin

Which condition indicates to the nurse that the treatment plan for a client with streptococcal pneumonia is effective? Client has been afebrile for 48 hours. Bronchial breath sounds present in lung periphery. White blood cell count is 16, 000 cells/mm3 (16 × 109/L). Oxygen saturation ranges between 90% and 92% on room air.

Client has been afebrile for 48 hours.

Which factors or conditions will the nurse identify as increasing the risk for clients to develop aspiration pneumonia? (Select all that apply.) Continuous nasogastric (NG) tube feedings Bronchoscopy procedure Magnetic resonance imaging (MRI) procedure Decreased level of consciousness Stroke Chest tube

Continuous nasogastric (NG) tube feedings Bronchoscopy procedure Decreased level of consciousness Stroke

Which order or prescription will the nurse perform first for a client admitted with pneumonia who is febrile and also agitated as a result of alcohol intoxication? Administering intravenous antibiotics Assessing the need for an immediate dose of lorazepam Drawing blood for aerobic and anaerobic blood cultures Requesting a referral to a social worker for alcohol counseling

Drawing blood for aerobic and anaerobic blood cultures

Which assessment finding in an older client with pneumonia will the nurse report immediately to the primary health care provider? SpO2 of 86% and confusion Hypotension and rapid, weak pulse Productive cough and normal temperature Flushed cheeks and increased respiratory rate

Hypotension and rapid, weak pulse

What is the nurse's first priority action to prevent harm when an 82-year-old client with pneumonia has become increasingly confused with an SpO2 change from 91% 1 hour ago to 88% now, and a respiratory rate that has increased from 26 to 32 breaths/min? Assisting the client to a more upright position Increasing the flow rate of the IV piggy-back antibiotic Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes Reporting the change in status to the client's primary health care provider

Increasing the oxygen flow rate by 2 L and reassessing in 5 minutes

Which adults will the nurse identify as having a higher risk for active tuberculosis? (Select all that apply.) Kidney transplant recipients Those in the local prison Homeless adults Recent immigrants to the United States Those who have received bacille Calmette-Guérin (BCG) vaccine Those who were treated previously for active tuberculosis

Kidney transplant recipients Those in the local prison Homeless adults Recent immigrants to the United States Those who were treated previously for active tuberculosis

Which complication of seasonal influenza will the nurse suspect in a 78-year-old client whose temperature remains elevated and now has new-onset confusion? Pneumonia Emphysema Heart failure Tuberculosis

Pneumonia

Which is the priority action for the nurse to take first after applying oxygen when caring for an older client admitted with symptoms of possible seasonal influenza accompanied by vomiting and high fever? Asking the client when symptoms began Administering IM influenza vaccination Starting an IV line to begin hydration therapy Placing the client in a negative air pressure room

Starting an IV line to begin hydration therapy

Which action to prevent harm is has the highest priority for the nurse to include when teaching a client with tuberculosis about the prescribed first-line drug therapy regimen? Expect a change in urine color. Be sure to drink at least 2 L of fluids daily. Take these drugs daily exactly as prescribed. Wear use sunscreen and wear protective clothing when you are out-of-doors.

Take these drugs daily exactly as prescribed.

What is the most important personal infection control measure that the nurse will take when suctioning a client with COVID-19 or any other pandemic influenza? Keeping the door to the client room closed Washing hands and donning gloves prior to the procedure Performing oral care before, as well as after, suctioning the oropharynx Wearing a disposable particulate mask N95 respirator with face shield or goggles

Wearing a disposable particulate mask N95 respirator with face shield or goggles