Question

The nurse is preparing to perform a tuberculin skin test using purified protein derivative (PPD). Which of the following interventions would be important for the nurse to include in the plan of care? (Select all that apply.)

Answer 1

Correct Answers:

Inform the client to return for an evaluation of redness 24-36 hours after
Ask the client about a history of receiving the Bacille Calmette-Guerin vaccine.
Instruct the client that they will need to return in 48-72 hours.

Rationale :

Inform the client to return for an evaluation of redness 24-36 hours after

✍️ Tuberculin skin tests (TST) require the client to return 24-72 hours after administration to assess for reaction.

✍️ Redness and induration (raised area) will be evaluated to determine if the client has been exposed to tuberculosis.

✍️ No evaluation should be made too soon, as it may not show a clear reaction in the early stages.

Ask the client about a history of receiving the Bacille Calmette-Guerin vaccine

◈ The BCG vaccine (used in countries with high tuberculosis rates) can cause a false positive on the tuberculin skin test.

◈ Understanding the client's vaccination history helps the nurse interpret test results accurately and differentiate between a true positive and a vaccine response.

◈ If the client received the BCG vaccine, further testing may be necessary to confirm the diagnosis.

Instruct the client that they will need to return in 48-72 hours

🍃 Tuberculin skin test evaluation should be performed 48-72 hours after administration to ensure proper measurement of redness or induration.

🍃 The reaction can be measured at this time for accurate results regarding exposure to tuberculosis.

🍃 Less than 48 hours will not provide accurate test results, as the reaction may still be developing.

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Answer 2

Correct Answers:

Place a surgical mask on the client when being transported through the facility.
Don a HEPA/N95 mask before entering the room to perform patient care.
Keep the door to the client's room closed

Rationale :

Place a surgical mask on the client when being transported through the facility.

◈ Pulmonary tuberculosis is airborne, and the client should wear a surgical mask to prevent spreading respiratory droplets while being transported.

◈ The surgical mask reduces exposure to others during movement outside the room.

◈ Transport should be kept to a minimum to avoid unnecessary exposure to the infectious air.

Don a HEPA/N95 mask before entering the room to perform patient care.

➥ Nurses should wear a HEPA/N95 mask to protect themselves from airborne particles containing Mycobacterium tuberculosis.

➥ N95 masks are designed to filter out the small droplets that carry tuberculosis bacteria.

➥ Standard surgical masks are not sufficient for protecting from airborne tuberculosis transmission.

Keep the door to the client's room closed.

✳️ Airborne precautions require that the client be placed in a negative pressure room with the door closed to contain and filter the air inside.

✳️Keeping the door closed helps limit exposure to others and maintain a controlled environment for infection prevention.

✳️ Ventilation in the room is important to reduce airborne transmission.

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Answer 3

Correct Answers:

Cough and sputum color, dyspnea, chest pain

Rationale :

➡️ Cough, sputum color, dyspnea, and chest pain are classic symptoms of community-acquired pneumonia.

➡️ Pneumonia causes inflammation in the lungs, leading to increased mucus production, resulting in productive cough and changes in sputum (yellow, green, or rust-colored).

➡️ Dyspnea (difficulty breathing) and chest pain from pleuritic involvement or inflammation in the lung lining are also common complaints in pneumonia.

➡️ The other symptoms, such as diaphoresis or hunger, are not typical indicators of pneumonia.

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Answer 4

Correct Answers:

Respiratory alkalosis

Rationale :

✳️ Respiratory alkalosis occurs when hyperventilation (rapid breathing) causes a loss of carbon dioxide (CO₂) from the blood, increasing blood pH.

✳️ The pH value of 7.5 is elevated, suggesting alkalosis.

✳️The HCO₃⁻ value of 22 mEq/L is within normal limits, indicating that the alkalosis is respiratory in origin.

✳️ The PaCO₂ level of 25 mm Hg is low, which confirms respiratory alkalosis since it represents the decreased CO₂ level in the blood.

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Answer 5

Correct Answers:

42.75

Rationale :

➥ Formula:

➡️ Dose to administer (mg) = Weight (kg)×Prescribed dose (mg/kg)

➧ Given:

Weight: 95 lbs

♦ Convert weight to kilograms:

♦95 lbs× 0.45 kg/lb = 42.75kg

Prescribed dose: 1 mg/kg

👉 Calculation:

➥42.75 kg ×1 mg/kg = 42.75mg ( rounded to the nearest tenth)

= 43.2mg

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Answer 6

Correct Answers:

Albuterol ipratropium nebulizer treatment

Rationale :

🔹 Albuterol is a beta-2 agonist that relaxes bronchial smooth muscle, improving airflow and relieving wheezing.

🔹 Ipratropium is an anticholinergic that decreases mucus secretion and promotes airway patency.

🔹 A combination nebulizer treatment is often indicated for bronchospasm with wheezing related to pneumonia.

🔹 This combination provides rapid relief and prevents airway obstruction progression.

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Answer 7

Correct Answers:

Attach a humidifier bottle to the oxygen delivery system

Rationale :

🟡 Oxygen at flows greater than 4 L/min can dry mucous membranes; using a humidifier prevents tissue irritation.

🟡 Humidification adds moisture, making oxygen therapy more comfortable and reducing the risk of mucosal injury.

🟡 Petroleum-based products like petroleum jelly are contraindicated because they are flammable with oxygen use.

🟡 Ensuring proper equipment setup improves client comfort and safety during therapy.

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Answer 8

Correct Answers:

"You will need to have liver function tests done frequently."

Rationale :

🔽 Pyrazinamide is hepatotoxic; frequent liver function monitoring is essential to detect early liver injury.

🔽 Clients taking this medication are at risk for elevated liver enzymes and hepatitis.

🔽 Education on the importance of lab monitoring helps prevent serious complications during TB treatment.

🔽 Vision testing is associated more with ethambutol, not pyrazinamide.

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Answer 9

Correct Answers:

Determine the oxygen saturation level.

Rationale :

✔️ Acute confusion in older adults can be an early sign of hypoxia or infection.

✔️ Checking oxygen saturation helps quickly rule out respiratory compromise as a cause of mental status changes.

✔️ Rapid assessment and intervention are necessary to prevent worsening of hypoxia and further neurological deterioration.

✔️ Hydration status is important but not the immediate priority over assessing oxygenation.

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Answer 10

Correct Answers:

Call the provider to ask about ordering a chest x-ray and sputum culture.
Place the client in a negative pressure airborne isolation room.
Place the client on supplemental oxygen.

Rationale :

🟧 Call the provider to ask about ordering a chest x-ray and sputum culture

▶️ Chest x-ray and sputum culture are critical for diagnosing pneumonia or other infectious respiratory diseases.

▶️ Identifying the pathogen early improves targeted treatment and reduces complications.

🟧 Place the client in a negative pressure airborne isolation room

▶️ Symptoms like fever, productive cough, and dyspnea could suggest tuberculosis, which requires airborne precautions until ruled out.

▶️ Early isolation protects other clients and healthcare workers from possible airborne transmission.

🟧Place the client on supplemental oxygen

▶️ Even with a normal oxygen saturation, the increased respiratory rate (tachypnea) and symptoms warrant supportive oxygen to reduce respiratory effort.

▶️ Oxygen helps maintain optimal perfusion during systemic infection and inflammation.

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QLexNursing

1 :
The nurse is preparing to perform a tuberculin skin test using purified protein derivative (PPD). Which of the following interventions would be important for the nurse to include in the plan of care? (Select all that apply.)

2 :
A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse take to prevent the spread of infection? (Select all that apply.)

3 :
When obtaining a health history from a patient suspected of having community-acquired pneumonia, the nurse should ask the patient about the presence of which of the following symptoms?

4 :
A nurse is caring for a client whose arterial blood gas results show a pH of 7.5, an HCO₃ of 22, and a PaC02 of 25 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

6 :
A client with pneumonia presents with wheezing on auscultation. The nurse would anticipate which medication to be ordered?

7 :
A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

8 :
A nurse is educating a client on the use of Pyrazinamide for tuberculosis. Which of the following statements is correct?

9 :
The nursing assistant reports to the registered nurse (RN) that an older adult client who has been alert and oriented has become increasingly confused over the past 3 hours. What would be the best nursing action to perform next?

10 :
The nurse in the emergency department is caring for a client who has an elevated temperature and reports fatigue and muscle aches.

Answer Options

QLexNursing

1 : The nurse is preparing to perform a tuberculin skin test using purified protein derivative (PPD). Which of the following interventions would be important for the nurse to include in the plan of care? (Select all that apply.)

2 : A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse take to prevent the spread of infection? (Select all that apply.)

3 : When obtaining a health history from a patient suspected of having community-acquired pneumonia, the nurse should ask the patient about the presence of which of the following symptoms?

4 : A nurse is caring for a client whose arterial blood gas results show a pH of 7.5, an HCO₃ of 22, and a PaC02 of 25 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

6 : A client with pneumonia presents with wheezing on auscultation. The nurse would anticipate which medication to be ordered?

7 : A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

8 : A nurse is educating a client on the use of Pyrazinamide for tuberculosis. Which of the following statements is correct?

9 : The nursing assistant reports to the registered nurse (RN) that an older adult client who has been alert and oriented has become increasingly confused over the past 3 hours. What would be the best nursing action to perform next?

10 : The nurse in the emergency department is caring for a client who has an elevated temperature and reports fatigue and muscle aches.

Answer Options

1 :
The nurse is preparing to perform a tuberculin skin test using purified protein derivative (PPD). Which of the following interventions would be important for the nurse to include in the plan of care? (Select all that apply.)

2 :
A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse take to prevent the spread of infection? (Select all that apply.)

3 :
When obtaining a health history from a patient suspected of having community-acquired pneumonia, the nurse should ask the patient about the presence of which of the following symptoms?

4 :
A nurse is caring for a client whose arterial blood gas results show a pH of 7.5, an HCO₃ of 22, and a PaC02 of 25 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

6 :
A client with pneumonia presents with wheezing on auscultation. The nurse would anticipate which medication to be ordered?

7 :
A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

8 :
A nurse is educating a client on the use of Pyrazinamide for tuberculosis. Which of the following statements is correct?

9 :
The nursing assistant reports to the registered nurse (RN) that an older adult client who has been alert and oriented has become increasingly confused over the past 3 hours. What would be the best nursing action to perform next?

10 :
The nurse in the emergency department is caring for a client who has an elevated temperature and reports fatigue and muscle aches.