Question 1

A patient who had a Mantoux test for tuberculosis two days ago has a 2 mm area of erythema at the site of the test. The nurse concludes that this patient's response

Accepted Answer

A Mantoux test is considered negative if the area of erythema is less than 5 mm in diameter for a patient who has no risk factors for tuberculosis. Therefore, a 2 mm area of erythema indicates a negative response to the Mantoux test.

Question 2

The nurse is caring for a patient diagnosed with severe acute respiratory syndrome (SARS). For what conditions should the nurse assess in this patient?

Accepted Answer

SARS is a respiratory illness that can lead to severe breathing difficulties. Nasal flaring (A) and restlessness (B) are signs of respiratory distress. Anxiety (C) can occur due to difficulty breathing. A decreased level of consciousness (D) may indicate severe hypoxia. Sputum production (E) is not typically associated with SARS.

Question 3

The nurse is teaching a patient prescribed isoniazid (INH). Select the patient statement that indicates a need for further medication instruction.

Accepted Answer

INH should not be taken immediately after eating breakfast. It should be taken on an empty stomach or at least 1 hour before or 2 hours after a meal. Therefore, the patient needs further medication instruction.

Question 4

A patient diagnosed with tuberculosis is prescribed ethambutol (EMB). Prior to initiating this medication, what should the nurse instruct the patient?

Accepted Answer

Ethambutol can cause visual changes or optic neuritis, so a baseline visual exam is necessary to monitor for any changes while taking the medication. Allergic reactions to eggs, flu vaccinations, and ECGs are not directly related to the use of ethambutol.

Question 5

A patient has a chest tube inserted for a pneumothorax. What should the nurse expect when assessing the drainage system?

Accepted Answer

Periodic bubbling in the water seal chamber is expected immediately after insertion as air is being evacuated from the pleural space.

Question 6

The nurse is caring for a patient on mechanical ventilation with positive end expiratory pressure (PEEP). When assessing the patient, which finding would indicate the possibility of tension pneumothorax?

Accepted Answer

Tension pneumothorax is a potentially life-threatening condition that occurs when air leaks into the pleural space and cannot escape, leading to increased pressure on the affected lung and mediastinal shift. One of the hallmark signs of tension pneumothorax is the sudden onset of absent or reduced breath sounds over the affected lung. While the other options may also be relevant to the patient's condition, they do not specifically suggest tension pneumothorax.

Question 7

A patient with a lung abscess is being discharged from the hospital. What should be included in this patient's discharge instructions?

Accepted Answer

Completing the entire prescription of antibiotics is crucial in treating lung abscesses to prevent recurrence or bacterial resistance.

Answer: C
 It is important for the patient to gradually return to routine activities of daily living as tolerated.

Answer: D
 This statement is false. Lung abscesses can cause complications such as pleural effusion or empyema, and follow-up appointments with the healthcare provider are necessary. Symptoms may also worsen if there is no improvement with treatment.

Question 8

A patient who is on isoniazid (INH) for pulmonary tuberculosis tells the nurse he doesn't like taking the medication because it makes his "fingers burn." The nurse concludes that the patient is experiencing which effect?

Accepted Answer

The patient is experiencing peripheral neuropathy, a common side effect of isoniazid (INH). Pyridoxine (vitamin B6) is often given with INH to prevent this side effect.

Question 9

A patient diagnosed with active tuberculosis is in a negative pressure room for respiratory airborne isolation. How long should the nurse maintain the patient in this type of isolation?

Accepted Answer

The patient should be maintained in respiratory airborne isolation until sputum specimens for acid-fast bacilli are negative. This is because it indicates that the patient is no longer infectious and poses a risk of spreading tuberculosis to others. The other choices listed do not provide an accurate indication of when the patient is no longer considered infectious.

Question 10

A patient who was admitted with symptoms of hypoxia is changed from a face mask to a nasal cannula for oxygen delivery. The nurse realizes that this patient's condition is

Accepted Answer

Changing from a face mask to a nasal cannula for oxygen delivery indicates that the patient's condition is improving as they may require less oxygen and can tolerate the lesser flow rate provided by the nasal cannula.

Question 11

A clinic is being conducted to provide influenza (flu) and pneumonia vaccines for adults. Prior to administration of a flu vaccine, for what should the nurse assess the patients?

Accepted Answer

Prior to administration of a flu vaccine, the nurse should assess if the patient has an allergy to eggs since most flu vaccines are made using eggs. If the patient is allergic to eggs, they may need to receive a different type of vaccine or be referred to an allergist for further evaluation. A, B, and C are not relevant to assessing for flu vaccine administration.

Question 12

A hospitalied patient is diagnosed with sudden acute respiratory syndrome (SARS). What action should the nurse implement immediately?

Accepted Answer

SARS is highly contagious and can spread through the air. Therefore, airborne precautions, in addition to standard and contact precautions, must be taken to prevent the spread of SARS. This includes wearing a properly fitted N95 mask, isolating the patient in a negative pressure room, and using airborne infection isolation precautions when transporting the patient.

Question 13

A patient with pneumonia is having difficulty maintaining a clear airway. Which actions should the nurse take to ensure this patient is adequately ventilated?

Accepted Answer

The answer of A patient with pneumonia is having difficulty...

Question 14

The nurse is caring for a patient with bacterial pneumonia. Which classifications of medications should the nurse expect to be prescribed for this patient?

Accepted Answer

The answer of The nurse is caring for a patient...

Question 15

A patient states, "I've been sick for days, and all the doctor does is take a chest x-ray, hand me prescriptions, and tell me I have bronchitis." The nurse realizes that this patient's treatment

Accepted Answer

Based on the patient's symptom of being sick for days and the doctor's diagnosis of bronchitis, it is appropriate for the doctor to take a chest x-ray to rule out pneumonia and prescribe medications such as antibiotics, bronchodilators, or cough suppressants to help alleviate symptoms. There is no indication from the patient's statement that additional diagnostic tests or hospitalization are necessary.

Question 16

A patient who is diagnosed with primary atypical pneumonia tells the nurse that he "doesn't feel too sick." What would be the nurse's best response?

Accepted Answer

Primary atypical pneumonia, also known as walking pneumonia, is typically less severe compared to other types of pneumonia. The nurse is providing the patient with accurate information about the illness. A is dismissive, B is not informative, and C assumes that the patient is recovering without evidence to support this claim.

Question 17

The nurse is assessing a patient recovering from a motor vehicle crash. Which assessment finding indicates that the patient is experiencing a pneumothorax?

Accepted Answer

Hyperresonance to percussion at the apex of the left lung is indicative of a pneumothorax, as it suggests the presence of air in the pleural space, leading to a decrease in lung density.

Question 18

A patient tells the nurse he had the bacilli Calmette-Guérin (BCG) vaccination as a child because his mother had tuberculosis. How should the nurse expect this patient to be screened for tuberculosis?

Accepted Answer

Since the patient received the BCG vaccine, which can cause a false positive result on skin tests for tuberculosis, the preferred method of screening for tuberculosis in this patient would be a chest x-ray.

Question 19

A patient is prescribed isoniazid (INH) and rifampin for treatment of tuberculosis. Which adverse effects should the nurse instruct the patient to report to the healthcare provider?

Accepted Answer

Yellow tint to the skin and change in stool color are adverse effects that should be reported to the healthcare provider.

Question 20

The nurse caring for a patient diagnosed with lung cancer determines that the patient might be experiencing superior vena cava syndrome. What did the nurse assess to make this clinical decision?

Accepted Answer

Superior vena cava syndrome is characterized by compression or obstruction of the superior vena cava, which can lead to swelling of the face and neck. Urine output and calcium levels are not related to this condition. Flat jugular veins may be a normal finding in some patients or may indicate hypovolemia, and are not specific to superior vena cava syndrome.

Quiz 36: Nursing Care of Patients With Ventilation Disorders