Question

A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first

Answer 1

Correct Answers:

Nucleic acid amplification test (NAAT)

Rationale :

🔷 NAAT is the fastest and most sensitive test for detecting Mycobacterium tuberculosis directly from sputum samples.

🔷 It detects genetic material (DNA/RNA) of TB, providing results in less than 24 hours.

🔷 Early detection is critical for preventing further transmission, especially in high-risk exposure cases.

🔷 Unlike chest X-rays or AFB smears, NAAT provides confirmatory molecular evidence even before cultures are positive.

🔷 NAAT is recommended by CDC as the first-line diagnostic test when TB is suspected in high-risk exposures.

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Answer 2

Correct Answers:

Assess pulse and respirations.

Rationale :

🔶 Baseline vital signs provide a reference to evaluate the client’s tolerance to the procedure.

🔶 Assessing respiratory rate and pulse helps monitor for distress during therapy.

🔶 It ensures safety especially in children with conditions like pneumonia.

🔶 Changes in these parameters can signal early complications or poor therapy response.

🔶 Priority nursing actions involve gathering baseline data before any intervention.

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Answer 3

Correct Answers:

"Expect your sputum cultures to be negative after 6 months of therapy."

Rationale :

💠 TB treatment typically lasts 6 to 9 months, and sputum culture conversion indicates treatment effectiveness.

💠 Negative sputum cultures by 6 months suggest successful bacterial clearance and therapeutic adherence.

💠 This statement sets realistic expectations for the client, reducing anxiety and improving compliance.

💠 TB medications like isoniazid and rifampin require long-term adherence to prevent resistance.

💠 Nurses should emphasize monitoring sputum status regularly to evaluate treatment progress.

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Answer 4

Correct Answers:

Instruct the client to use pursed-lip breathing

Rationale :

🟢 Pursed-lip breathing prolongs exhalation, reducing air trapping and dyspnea in COPD patients.

🟢 It creates a back-pressure in the airways, keeping them open and enhancing oxygen exchange.

🟢 This technique reduces respiratory rate and improves tidal volume.

🟢 It empowers clients with self-regulation techniques to manage breathlessness.

🟢 Especially useful during exertion or episodes of SOB, making it a cornerstone of COPD management.

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Answer 5

Correct Answers:

Administer oxygen via nasal cannula.

Rationale :

🔴 Immediate oxygen administration helps stabilize oxygenation in clients with open chest injuries.

🔴 It supports tissue perfusion while preparing for definitive interventions like chest tube insertion.

🔴 Sucking chest wounds compromise ventilation by allowing air into the pleural space, creating a pneumothorax.

🔴 Oxygen helps reduce hypoxia and prevents respiratory failure, especially with RR 40/min.

🔴 Prompt oxygenation can be lifesaving while other emergency actions are underway.

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Answer 6

Correct Answers:

Fluctuation of the fluid level within the water seal chamber

Rationale :

🔵 Tidaling (fluid fluctuation) with respiration confirms a patent chest tube and effective drainage.

🔵 The water seal acts as a one-way valve, allowing air or fluid to exit but not re-enter.

🔵 Lack of fluctuation may signal obstruction or full lung re-expansion.

🔵 Continuous bubbling is not normal; intermittent bubbling or tidaling is expected.

🔵 Monitoring the water seal chamber helps prevent tension pneumothorax or tube complications.

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Answer 7

Correct Answers:

Place in a prone position

Rationale :

🟣 Prone positioning improves ventilation-perfusion matching in ARDS by redistributing blood flow.

🟣 It enhances oxygenation by allowing better alveolar expansion and secretion drainage.

🟣 In severe ARDS, prone therapy is evidence-based and lifesaving, used along with mechanical ventilation.

🟣 It helps reduce lung compression by the heart and diaphragm, increasing functional lung volume.

🟣 Frequent repositioning prevents pressure injuries and optimizes respiratory mechanics.

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Answer 8

Correct Answers:

No fluctuations in the water seal chamber

Rationale :

🟡 Absence of fluctuation can mean that the lung has fully re-expanded, eliminating pleural air/fluid shifts.

🟡 After full re-expansion, there is no longer a pressure gradient, so tidaling stops.

🟡 Confirm with chest X-ray to ensure the lung is re-inflated and chest tube can be removed soon.

🟡 Important to differentiate this from a blocked tube—other signs must align (improved oxygenation, no bubbling).

🟡 Monitoring chest tube output and respiratory status remains essential.

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Answer 9

Correct Answers

Blank 1 Correct Option: Asthma
Blank 2 Correct Option: Measure the client's peak airflow and Plan to administer a bronchodilator
Blank 3 Correct Option: Pulmonary function tests and Oxygen saturation

Rationale :

🟠 Symptoms such as wheezing, cough, and dyspnea at night are classic features of asthma.

🟠 Inspiratory/expiratory wheezes with dry cough and chest tightness strongly support the diagnosis.

🟠 History of nonsmoker + GERD increases asthma risk due to reflux-related airway irritation.

🟠 Vital signs show tachypnea and low O₂ saturation, common in asthma exacerbations.

🟠 No fever or productive cough suggests it is not bacterial pneumonia.

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Answer 10

Correct Answers:

“This test is performed if previous results are negative."

Rationale :

🟥 The intradermal PPD test is used for initial screening in individuals with no known prior TB exposure or negative tests.

🟥 Once positive, PPD is not repeated; further screening is done via chest X-ray or sputum testing.

🟥 Repeated PPDs in those with positive histories can cause adverse skin reactions.

🟥 This question ensures proper sequence of testing and screening protocols.

🟥 Nurses must educate clients on why the test is performed and how it's interpreted.

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Custom Adult Health 2EX1

No.

1 :
A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first

2 :
A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?

3 :
A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin and pyrazinamide. Which of the following instructions should the nurse include?

4 :
A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

5 :
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

6 :
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

7 :
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

8 :
A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

9 :
A nurse in an emergency department is caring for a client

Correct Answers

10 :
A nurse is teaching a client about the intradermal purified protein derivative (PPD). Which of the following information should the nurse include?

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Custom Adult Health 2EX1

No.

1 : A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first

2 : A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?

3 : A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin and pyrazinamide. Which of the following instructions should the nurse include?

4 : A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

5 : A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

6 : The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

7 : A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

8 : A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

9 : A nurse in an emergency department is caring for a client

Correct Answers

10 : A nurse is teaching a client about the intradermal purified protein derivative (PPD). Which of the following information should the nurse include?

1 :
A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first

2 :
A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?

3 :
A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin and pyrazinamide. Which of the following instructions should the nurse include?

4 :
A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

5 :
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

6 :
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

7 :
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

8 :
A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

9 :
A nurse in an emergency department is caring for a client

10 :
A nurse is teaching a client about the intradermal purified protein derivative (PPD). Which of the following information should the nurse include?