Question

A nurse in a community health center is assessing the results of a tuberculin skin test she performed for a client that applied for a position as RN. Which of the following results indicates a negative result or no exposure to tuberculosis (TB)?

Answer 1

Correct Answers:

6 mm induration

Rationale :

💠 Tuberculin skin test (PPD) interpretation is based on induration, not erythema, meaning the area of firmness is measured rather than redness.

💠 For healthcare workers, an induration of 10 mm or greater is considered a positive result.

💠 An induration of 6 mm is below the positive threshold for this risk group and is therefore considered negative.

💠 A negative result suggests no evidence of TB exposure or infection, though clinical correlation is always required.

💠 Proper measurement of the raised, firm area in millimeters ensures accurate interpretation of TB screening results.

10 mm wheal

💠 A 10 mm measurement would be considered positive in a healthcare worker.

💠 The term wheal is incorrect because interpretation is based on induration, not superficial swelling.

8 mm erythema

💠 Erythema (redness) is not used to interpret TB skin test results.

💠 Only the indurated area determines whether the test is positive or negative.

10 mm induration

💠 A 10 mm induration meets the positive criteria for a healthcare worker.

💠 This finding suggests possible TB exposure or latent infection.

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Answer 2

Correct Answers:

Tape the connections on the client's chest tube.

Rationale :

💠 Taping chest tube connections helps maintain a closed drainage system, which is essential to prevent air leaks and potential pneumothorax recurrence.

💠 Secure connections reduce the risk of accidental disconnection, which can rapidly compromise lung re-expansion.

💠 Maintaining system integrity ensures proper negative pressure within the drainage unit.

💠 A closed system prevents entry of atmospheric air, reducing the risk of tension pneumothorax.

💠 Proper stabilization of tubing connections is a key safety intervention in chest tube management.

Loop the tubing of the chest tube on the client's bed.

💠 Looping tubing on the bed can cause dependent loops, leading to fluid accumulation and impaired drainage.

💠 Tubing should be positioned to allow continuous gravity drainage without obstruction.

Place the chest tube drainage system above the level of the client's heart.

💠 The drainage system must remain below the level of the chest to promote gravity flow.

💠 Placing it above the chest increases the risk of backflow of drainage into the pleural space.

Clamp client's chest tubes every 2 hrs for 15 seconds.

💠 Routine clamping can increase the risk of tension pneumothorax by trapping air in the pleural space.

💠 Chest tubes are only clamped under specific provider orders or during system changes, not routinely.

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Answer 3

Correct Answers:

Use pillows under the client's calf to keep heels off the bed surface.
Minimize skin exposure to moisture.

Rationale :

💠 Offloading pressure from the heels prevents prolonged compression of bony prominences, which are highly susceptible to pressure injury.

💠 Elevating the calves allows the heels to float freely, reducing ischemia caused by sustained pressure.

💠 Clients with spinal cord injury and paralysis have impaired sensation and cannot reposition independently, increasing risk.

💠 Relieving pressure improves circulation and tissue perfusion, essential for maintaining skin integrity.

💠 Proper positioning is a core intervention in pressure injury prevention protocols.

Minimize skin exposure to moisture.

💠 Excess moisture from urine, stool, or perspiration weakens the skin barrier and increases breakdown risk.

💠 Prolonged moisture leads to maceration, making skin more vulnerable to friction and shear.

💠 Maintaining clean, dry skin supports epidermal integrity and reduces infection risk.

💠 Using moisture barriers and frequent hygiene care protects compromised areas.

💠 Moisture control is a key component of pressure injury prevention strategies.

Massage over erythematous bony prominences.

💠 Massaging reddened areas can cause capillary damage and worsen tissue injury.

💠 Non-blanchable erythema indicates early pressure injury and should not be manipulated.

Keep the client's skin dry with powder.

💠 Excess powder can cause skin irritation and friction.

💠 Moisture management should focus on barrier products, not routine powder use.

Implement turning schedule every 4 hr.

💠 High-risk clients require repositioning at least every 2 hours, not every 4 hours.

💠 Extended intervals increase risk of pressure-induced ischemia.

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Answer 4

Correct Answers:

Sputum culture for acid-fast bacillus

Rationale :

💠 Sputum culture for acid-fast bacillus (AFB) is the gold standard for confirming active pulmonary tuberculosis.

💠 A culture identifies the presence of Mycobacterium tuberculosis and confirms active infection rather than latent exposure.

💠 It allows for drug susceptibility testing, which is essential for selecting effective antitubercular therapy.

💠 Although results take longer, culture provides the most definitive and reliable diagnosis.

💠 Confirming active TB is critical to initiate appropriate treatment and infection control precautions.

Chest X ray

💠 A chest X-ray can suggest TB by showing infiltrates or cavitations but cannot definitively confirm active infection.

💠 Radiographic findings are supportive but not diagnostic without microbiologic evidence.

Sputum smear

💠 A sputum smear can detect acid-fast organisms quickly but has lower sensitivity than culture.

💠 It does not provide definitive confirmation or drug susceptibility information.

Mantoux test

💠 The Mantoux (tuberculin skin) test detects prior exposure, not active disease.

💠 A positive result cannot distinguish between latent and active TB infection.

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Answer 5

Correct Answers:

0.4

Rationale :

💠 Convert grams to milligrams since the order is in mg:

3 g = 3,000 mg

💠 Set up the ratio using the supply concentration:

3,000 mg : 5 mL

💠 Determine how many mL per 1 mg:

5 mL ÷ 3,000 mg = 0.00167 mL per mg

💠 Multiply by the ordered dose (250 mg):

0.00167 × 250 = 0.4167 mL

💠 Round to the nearest tenth:

0.4167 ≈ 0.4 mL

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Answer 6

Correct Answers:

Arterial blood gas results
Oxygen saturation
Shortness of breath
Lung sounds

Rationale :

Arterial blood gas results

💠 Elevated PaCO₂ of 65 mm Hg indicates significant hypercapnia, reflecting worsening ventilatory failure.

💠 Low PaO₂ of 59 mm Hg confirms severe hypoxemia, requiring urgent intervention.

💠 The near-normal pH of 7.37 with elevated HCO₃ of 35 mEq/L suggests compensated respiratory acidosis, but compensation does not eliminate the acute risk.

💠 These findings indicate impaired gas exchange and possible impending respiratory failure.

💠 Immediate action is required to improve oxygenation and ventilation.

Oxygen saturation

💠 A drop in oxygen saturation to 83% indicates critical hypoxemia.

💠 Saturation below 88% in COPD patients suggests inadequate tissue oxygenation.

💠 Cyanosis and delayed capillary refill support worsening oxygen deprivation.

💠 Severe desaturation increases risk for cardiac dysrhythmias and organ dysfunction.

💠 Immediate oxygen therapy and respiratory support are necessary.

Shortness of breath

💠 Increasing dyspnea signals worsening airflow obstruction.

💠 Orthopneic positioning and use of accessory muscles indicate increased work of breathing.

💠 Rapid progression from mild to severe symptoms suggests acute respiratory decompensation.

💠 Untreated respiratory distress can lead to fatigue and respiratory arrest.

💠 This symptom reflects a need for urgent respiratory support.

Lung sounds

💠 Worsening wheezing and diminished breath sounds indicate increased air trapping and bronchospasm.

💠 Decreased air movement may signal impending respiratory failure.

💠 In COPD exacerbation, worsening lung sounds correlate with impaired ventilation.

💠 Persistent wheezing with hypoxia suggests severe airway obstruction.

💠 Immediate intervention such as bronchodilators may be required.

Barrel chest

💠 Barrel chest is a chronic finding in COPD and not an acute change.

💠 It does not indicate sudden deterioration requiring immediate intervention.

Electrocardiogram results

💠 The ECG shows sinus rhythm, which is a normal finding.

💠 There is no evidence of acute cardiac dysrhythmia requiring urgent action.

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Answer 7

Correct Answers:

Oral Candidiasis

Rationale :

💠 Inhaled corticosteroids suppress local immune function in the oral mucosa, increasing susceptibility to fungal overgrowth.

💠 A white, milky plaque that does not rub off easily is characteristic of oral thrush, caused by Candida albicans.

💠 Recent antibiotic therapy disrupts normal oral flora, further promoting fungal proliferation.

💠 Symptoms such as mouth soreness and difficulty eating are common manifestations of oral candidiasis.

💠 Smoking and chronic respiratory conditions can also contribute to oral mucosal irritation, increasing infection risk.

Leukoplakia

💠 Leukoplakia presents as white patches but is typically associated with chronic irritation such as tobacco use.

💠 It is not commonly linked to recent antibiotic or corticosteroid use.

Herpes simplex type 1

💠 Herpes simplex virus type 1 usually presents with painful vesicles or ulcers, not thick white plaques.

💠 Lesions are often preceded by tingling or burning, rather than diffuse milky patches.

Dermatitis

💠 Dermatitis involves inflammation of the skin, not the oral mucosa.

💠 It does not present as white plaques inside the mouth.

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Answer 8

Correct Answers:

WBC count

Rationale :

💠 An elevated white blood cell (WBC) count is a primary indicator of an active infection as the body increases leukocyte production to fight invading pathogens.

💠 In a client with a pressure ulcer, bacterial colonization can progress to local or systemic infection, triggering leukocytosis.

💠 Increased WBC levels reflect activation of the immune response, particularly neutrophils in bacterial infections.

💠 Monitoring WBC trends helps detect worsening infection or potential sepsis.

💠 Early identification of elevated WBC allows prompt initiation or adjustment of antibiotic therapy.

RBC count

💠 The red blood cell (RBC) count reflects oxygen-carrying capacity, not infection status.

💠 Changes in RBC levels are more associated with anemia or blood loss, not acute infection.

Potassium

💠 Potassium levels are related to electrolyte balance and cardiac function.

💠 They are not specific indicators of infection.

BUN

💠 Blood urea nitrogen (BUN) evaluates kidney function and hydration status.

💠 It does not directly indicate the presence of an infectious process.

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Answer 9

Correct Answers:

Chronic cough
Sputum production
Dyspnea
Wheezing

Rationale :

Chronic cough

💠 A chronic cough is a hallmark symptom of chronic obstructive pulmonary disease (COPD), especially in chronic bronchitis.

💠 Persistent airway inflammation leads to mucus hypersecretion, triggering continuous coughing.

💠 The cough is typically present for at least 3 months per year for 2 consecutive years in chronic bronchitis.

💠 Chronic cough reflects ongoing airway irritation and obstruction.

💠 It is often one of the earliest reported symptoms in COPD.

Sputum production

💠 Excess sputum production results from hypertrophy of mucus glands and increased goblet cells in the airways.

💠 Thick mucus contributes to airflow limitation and airway obstruction.

💠 Chronic sputum production is strongly associated with chronic bronchitis, a type of COPD.

💠 Accumulated secretions impair gas exchange and promote infections.

💠 This symptom commonly accompanies chronic cough.

Dyspnea

💠 Dyspnea is a key symptom caused by air trapping and hyperinflation of the lungs.

💠 Progressive airflow obstruction increases the work of breathing.

💠 Clients often experience shortness of breath first with exertion, later at rest.

💠 Dyspnea reflects worsening ventilation-perfusion mismatch.

💠 It significantly impacts functional capacity and quality of life.

Wheezing

💠 Wheezing occurs due to narrowed airways and turbulent airflow.

💠 Bronchospasm and inflammation contribute to airway constriction.

💠 Wheezing is commonly heard during expiration in COPD exacerbations.

💠 It indicates ongoing airflow obstruction.

💠 Persistent wheezing suggests disease progression or acute exacerbation.

Chest tightness

💠 Chest tightness is more commonly associated with asthma rather than classic COPD presentation.

💠 Although it may occur, it is not considered one of the most common defining manifestations of COPD.

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Answer 10

Correct Answers:

Ventilate the patient using a manual resuscitation bag and facemask

Rationale :

💠 A newly placed tracheostomy that becomes dislodged can rapidly compromise the airway, making oxygenation the first priority.

💠 Immediate manual ventilation with a bag-valve mask ensures delivery of oxygen while maintaining airway support.

💠 In a fresh tracheostomy, the stoma tract is not well established, so blind reinsertion may create a false passage.

💠 According to ABCs (Airway, Breathing, Circulation), restoring ventilation takes precedence over calling for assistance.

💠 Once oxygenation is stabilized, additional support and airway replacement can be safely arranged.

Call the Rapid Response Team and wait for assistance and new order

💠 Delaying intervention while waiting can result in hypoxia and respiratory arrest.

💠 Immediate action to support breathing must occur before seeking additional help.

Apply gentle tension on the stay sutures to reopen the trachea

💠 Stay sutures may help maintain stoma patency but do not guarantee effective ventilation.

💠 Oxygenation must be supported immediately before attempting structural correction.

Insert a new tracheostomy tube immediately

💠 In early postoperative periods, reinsertion can cause a false passage or trauma.

💠 Airway stabilization with bag-valve-mask ventilation is safer as the first response.

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QLexNursing

1 :
A nurse in a community health center is assessing the results of a tuberculin skin test she performed for a client that applied for a position as RN. Which of the following results indicates a negative result or no exposure to tuberculosis (TB)?

2 :
A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

3 :
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select All that Apply.)

4 :
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis, which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?

5 :
A nurse is preparing to administer 250 mg of an antibiotic IM. Available is 3 g/5 ml. How many ml should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

6 :
A nurse is caring for a client who has been admitted with chronic obstructive pulmonary disease.

Answer Options

8 :
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

9 :
Which of the following are the most common manifestations of COPD (Select all that apply)

10 :
A nurse providing care to a client with a newly placed tracheostomy finds the tracheostomy tube on the client's chest and the client coughing. What is the nurse's immediate action to ensure patient safety?

QLexNursing

1 : A nurse in a community health center is assessing the results of a tuberculin skin test she performed for a client that applied for a position as RN. Which of the following results indicates a negative result or no exposure to tuberculosis (TB)?

2 : A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

3 : A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select All that Apply.)

4 : A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis, which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?

5 : A nurse is preparing to administer 250 mg of an antibiotic IM. Available is 3 g/5 ml. How many ml should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

6 : A nurse is caring for a client who has been admitted with chronic obstructive pulmonary disease.

Answer Options

8 : A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

9 : Which of the following are the most common manifestations of COPD (Select all that apply)

10 : A nurse providing care to a client with a newly placed tracheostomy finds the tracheostomy tube on the client's chest and the client coughing. What is the nurse's immediate action to ensure patient safety?

1 :
A nurse in a community health center is assessing the results of a tuberculin skin test she performed for a client that applied for a position as RN. Which of the following results indicates a negative result or no exposure to tuberculosis (TB)?

2 :
A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

3 :
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select All that Apply.)

4 :
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis, which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?

5 :
A nurse is preparing to administer 250 mg of an antibiotic IM. Available is 3 g/5 ml. How many ml should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

6 :
A nurse is caring for a client who has been admitted with chronic obstructive pulmonary disease.

8 :
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

9 :
Which of the following are the most common manifestations of COPD (Select all that apply)

10 :
A nurse providing care to a client with a newly placed tracheostomy finds the tracheostomy tube on the client's chest and the client coughing. What is the nurse's immediate action to ensure patient safety?