Chapter 33: Care of Patients with Infectious Respiratory Problems Nursing School Test Banks

Chapter 33: Care of Patients with Infectious Respiratory Problems

Test Bank

MULTIPLE CHOICE

1. A client has acute rhinitis. What is the most important intervention for the nurse to perform?

a.

Assess for symptoms of infection.

b.

Ascertain whether the client has allergies.

c.

Question the client on the use of nasal sprays.

d.

Do blood and urine screenings for drug use.

ANS: A

Bacterial infection often occurs with acute rhinitis. The nurse should assess for symptoms because treatment may be warranted. It is not essential to assess for allergies or the use of nasal spray, or to determine whether drug use is occurring. All of these interventions are focused on determining a cause for repeated acute rhinitis and are primarily the responsibility of the health care provider. The nurse should focus on client assessment and should determine whether a secondary infection is present.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Implementation)

2. A client has pharyngitis. Which symptom helps the nurse determine whether the infection is bacterial versus viral?

a.

Redness in the back of the throat

b.

Enlarged lymph glands in the neck

c.

Nasal discharge

d.

Skin rash

ANS: D

Generally a rash can appear with bacterial pharyngitis, but not with viral. The other symptoms are characteristic of both.

DIF: Cognitive Level: Comprehension/Understanding REF: Chart 33-2, p. 643

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. It is suspected that a client has bacterial pharyngitis. What is the best intervention?

a.

Administer a broad-spectrum antibiotic.

b.

Have the client produce a sputum specimen.

c.

Obtain samples for culture and sensitivity.

d.

Assess a rapid antigen test (RAT).

ANS: D

A common cause of bacterial pharyngitis is group A streptococcal virus, which can lead to serious complications. Both RATs and culture and sensitivity can diagnose this bacterium; however, with an RAT, the health care provider can obtain results in about 15 minutes, and definitive treatment can begin much sooner. A broad-spectrum antibiotic would not be administered before it was determined whether the infection was bacterial. A sputum specimen is needed for lung infection but not for throat infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Nursing Process (Implementation)

4. The nurse is caring for a client with recurrent bacterial pharyngitis. Which is the nurses highest priority intervention?

a.

Assess for symptoms of human immune deficiency virus (HIV).

b.

Ask about exposure to allergens.

c.

Perform nasal cultures.

d.

Teach the client about antibiotic therapy.

ANS: D

Management of bacterial pharyngitis involves the use of antibiotics and the same supportive care provided for viral pharyngitis. Stress the importance of completing the entire antibiotic prescription, even when symptoms improve or subside. Failure to take all prescribed antibiotics is often the cause of recurrent infections. Although it is important for overall health that the client know his or her HIV status, it is not the highest priority intervention in the treatment plan. Allergens do not cause bacterial infections. Nasal cultures would not be a high priority unless the client had failed treatment with more than one antibiotic and was compliant with treatment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Teaching/Learning

5. A client who has had acute tonsillitis develops drooling and reports severe throat pain. What is the nurses priority intervention?

a.

Assess the throat for deviation of the uvula.

b.

Prepare the client for surgery.

c.

Teach the client about antibiotic therapy.

d.

Prepare the client for percutaneous needle aspiration.

ANS: A

The nurse should first assess the throat for signs of peritonsillar abscess. If present, the nurse should call the health care provider immediately because aspiration of the abscess may be needed to maintain the airway.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

6. The nurse has determined that a client has an acute sore throat. What is the nurses best action?

a.

Assess whether the client can speak.

b.

Call an ear-nose-throat specialist.

c.

Administer an antibiotic.

d.

Give the client ice chips.

ANS: A

A dry cough and difficulty swallowing may indicate that the client is developing laryngitis. The nurse should assess whether the client can speak or shows any changes in his or her voice. The other interventions are not appropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction in Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

7. A client who is immune compromised develops muscle aches and fever. The client is admitted to the hospital for several days and is diagnosed with influenza. At discharge, the client asks when he can go back to work. What is the nurses best response?

a.

You should be able to return to work in 5 days.

b.

You can return to work as soon as you feel ready.

c.

You cannot return to work for several weeks.

d.

You will need to have cultures performed before returning to work.

ANS: C

Immune compromised clients are contagious for several weeks. The client should remain at home until he is not contagious.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 645

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

8. A client is worried about contracting influenza. What is the nurses best response to the client?

a.

Flu is no longer a prevalent problem.

b.

Did you receive a flu vaccine this year?

c.

Current flu strains are generally mild.

d.

If you develop symptoms, antibiotics will cure you.

ANS: B

Vaccines for influenza are widely available and are recommended to prevent flu. Flu continues to be a major problem, affecting up to 20% of the U.S. population and causing 36,000 deaths annually.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 645

TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Nursing Process (Implementation)

9. The nurse assesses a client with pneumonia and notes decreased lung sounds on the left side and decreased lung expansion. What is the nurses best action?

a.

Have the client cough and deep breathe.

b.

Check oxygen saturation and notify the health care provider.

c.

Perform an arterial blood gas analysis.

d.

Increase oxygen flow to 10 L/min.

ANS: B

Decreased lung sounds and decreased lung expansion could indicate the development of a complication such as empyema or pus in the pleural space. The nurse should check the clients oxygen saturation and notify the provider. Infection can also move into the bloodstream and result in sepsis, so quick treatment is needed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Implementation)

10. An older adult is admitted to the emergency department with respiratory symptoms. Which client symptom requires the nurse to intervene immediately?

a.

Confusion

b.

Scattered wheezing

c.

Crackles

d.

Flushed cheeks

ANS: A

Confusion in an older adult can signify hypoxia. If the nurse waited to intervene until the older adult showed more traditional symptoms of pneumonia, the client may become critically ill. The other manifestations also require intervention but not as the priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)

MSC: Integrated Process: Nursing Process (Implementation)

11. Which is the highest priority goal to set for a client with pneumonia?

a.

Absence of cyanosis

b.

Maintenance of SaO2 of 95%

c.

Walking 20 feet three times daily

d.

Absence of confusion

ANS: B

Maintenance of an SaO2 of at least 95% is a clear goal that indicates that the client has adequate oxygenation. Absence of cyanosis and the presence of confusion are assessment factors that contribute to evaluation of oxygen; however, they are not absolute measures. Likewise, walking three times a day does not directly address oxygenation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Planning)

12. The nurse is teaching a client with pneumonia ways to clear secretions. Which intervention is the most effective?

a.

Administering an antitussive medication

b.

Administering an antiemetic medication

c.

Increasing fluids to 2 L/day if tolerated

d.

Having the client cough and deep breathe hourly

ANS: C

Increasing fluids has been proven to decrease the thickness of secretions, thus allowing them to be expectorated quickly. The other interventions would not be as effective.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Teaching/Learning

13. A client who works in a day care facility is admitted to the emergency department. The client is diagnosed with pneumonia, and a sputum culture is taken. Infection with Streptococcus pneumoniae is confirmed. What is the nurses primary action?

a.

Have emergency intubation equipment nearby.

b.

Teach the client about the treatment.

c.

Isolate the client.

d.

Perform chest physiotherapy.

ANS: C

The client who works in a day care facility and is infected with Streptococcus pneumoniae may have a drug-resistant pneumonia. It is extremely important that this organism does not spread to other clients; the client should be isolated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

14. What is the priority nursing intervention when caring for a client with severe acute respiratory syndrome (SARS)?

a.

Maintaining Standard Precautions

b.

Administering antibiotics

c.

Assessing oxygenation

d.

Making sure the client stays hydrated

ANS: C

The client with SARS can rapidly develop hypoxia. Assessing oxygenation is a priority because intubation and mechanical ventilation may be needed. Maintaining precautions is essential for preventing the spread of this illness, but oxygenation and client safety are the highest priorities. Antibiotics are administered if bacterial pneumonia occurs with this disease. Hydration is important to make sure secretions stay liquefied; this is also secondary to oxygenation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

15. The newly employed nurse received a bacillus Calmette-Gurin (BCG) vaccine before moving to the United States. The nurse needs to receive a tuberculin (TB) test as part of the pre-employment physical. What does the nurse do?

a.

The nurse should not receive the tuberculin test.

b.

The nurse will need a two-step TB test.

c.

The nurse will need a chest x-ray instead.

d.

A physician should examine the nurse before the TB test is given.

ANS: C

The bacillus Calmette-Gurin (BCG) vaccine contains attenuated tubercle bacilli and is used in many countries to produce increased resistance to TB. The nurse will have a positive skin test. The client should be evaluated for TB with a chest x-ray. A physician examination is not necessary.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Implementation)

16. The nurse is caring for several clients on a respiratory floor. The nurse should place the client with which condition in isolation?

a.

Fever and weight loss

b.

Negative QuantiFERON TB gold test

c.

Negative acid-fast bacillus (AFB) stain

d.

Positive nucleic acid amplification test (NAAT)

ANS: D

The NAAT is a new rapid test for the diagnosis of tuberculosis (TB). Results are available in less than 2 hours. A positive test is conclusive for TB, and the client should be placed in isolation per facility policy. A client with a negative QuantiFERON gold test would not have tuberculosis. Likewise, a client with a negative AFB would not have tuberculosis. The client with fever and weight loss could have tuberculosis, but diagnostic tests would be needed because these are nonspecific manifestations.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)

17. A client has multidrug-resistant tuberculosis (TB). What is the most important fact for the nurse to teach the client?

a.

You will need to take medications longer than clients with other strains.

b.

You will need to remain in the hospital until cultures are negative.

c.

You will need to wear a mask when you go out in public.

d.

You will need to have drug cultures done weekly.

ANS: C

The client should wear a mask when out of the home environment and in crowds to prevent spread of the infection. The other statements are not accurate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Teaching/Learning

18. The nurse is worried that a client who is not entirely reliable is being discharged home on therapy for multidrug-resistant tuberculosis. What strategy is the best to use for this client?

a.

Directly observed therapy

b.

IV drug administration

c.

Remaining in the hospital

d.

Isolation

ANS: A

If a client is not reliable, the risk is that the client will not take medications as required, causing spread of an organism that may become more drug resistant. The other answers are not correct.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

19. A client is admitted with suspected avian influenza. The family asks the nurse what kind of care the client will get. Which statement by the nurse is correct?

a.

He will be given standard antibiotic agents and will be placed in contact isolation.

b.

He will be placed on airborne and contact isolation.

c.

Oseltamivir (Tamiflu) will reduce complications of this infection.

d.

All family members should be tested for evidence of the same disease.

ANS: B

The client who is experiencing avian influenza should be on both airborne and contact isolation. Standard antibiotic agents would be ineffective with this disease process, as would most of the standard antiviral medications commonly used for influenza. Human-to-human contact through family members is likely only in very close living arrangements, so only specific members of the clients family should consider diagnostic testing.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Assessment)

20. Which client does the nurse caution to avoid taking over-the-counter decongestants for manifestations of a cold or flu?

a.

Young man with a latex allergy

b.

Middle-aged woman with hypertension

c.

Teenage woman who is taking oral contraceptives

d.

Older man who has had type 1 diabetes mellitus for 20 years

ANS: B

Most decongestants work by increasing blood vessel constriction. This action increases peripheral vascular resistance and blood pressure. The client who already has hypertension may develop dangerously high blood pressure when taking a decongestant. The client who has a latex allergy, is taking oral contraceptives, or has type 1 diabetes would not be likely to be affected by the decongestant in such a life-threatening manner as the client who is hypertensive.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Assessment)

21. An older client reports having a cold and a full bladder. What does the nurse obtain for or from the client?

a.

Order for a Foley catheter

b.

Order for a one-time catheterization

c.

Urine specimen

d.

History focusing on current medications

ANS: D

The nurse needs to assess more before intervening. Clients often take antihistamines for a cold. Antihistamines are often composed of anticholinergic drugs. In older adult clients, these medications can cause or worsen urinary retention.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Assessment)

22. A client has a peritonsillar abscess. Which priority instruction does the nurse provide to this client?

a.

If you notice an enlarged node on the side of your neck where the abscess is, call your health care provider.

b.

Stay home from work or school until your temperature has been normal for 24 hours.

c.

You may gargle with warm water that has a teaspoon of salt in it as often as you like.

d.

Take the antibiotic for the entire time it is prescribed, not just until you feel better.

ANS: D

Untreated or ineffectively treated peritonsillar abscesses can extend throughout the pharyngeal area, causing swelling that may jeopardize the clients airway. Therefore, the client should take his antibiotic for the entire time prescribed to maximize the therapeutic effect. Gargling with warm water and refraining from normal activities may provide symptomatic relief for the client but would not be considered priority instructions. Also, swelling, pain, and inflammation could be noted by the client on the same side of the neck as the abscess.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 644

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC: Integrated Process: Teaching/Learning

23. An older adult client with heart failure asks if she should get a flu shot. Which is the nurses best response?

a.

Yes, because of your heart failure you are at greater risk for complications.

b.

Yes, if it has been longer than 5 years since your last flu vaccination.

c.

No, your heart failure makes you too weak to get the live virus vaccine.

d.

No, the vaccine will interact with your heart medications.

ANS: A

People older than 50 years and those with chronic disease should be vaccinated against the flu each year early in the fall because they are at higher risk of developing complications if they do get ill. Flu shots appear to be effective for only one flu season, so the client should get one annually. The live vaccine is recommended only for healthy people up to age 49. This vaccination should not have interactions with heart medications.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 645

TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Teaching/Learning

24. Which person is at greatest risk for developing a community-acquired pneumonia?

a.

Middle-aged teacher who typically eats a diet of Asian foods

b.

Older adult who smokes and has a substance abuse problem

c.

Older adult with exercise-induced wheezing

d.

Young adult aerobics instructor who is a vegetarian

ANS: B

Although age is a factor in the development of community-acquired pneumonia, other lifestyle and exposure factors increase the risk to a greater extent than age. Two conditions that heavily predispose to the development of pneumonia are cigarette smoking and alcoholism. Dietary choices typically do not predispose to the development of pneumonia. Cigarette smoking interferes with the ciliary function of removal of invasive materials. Alcoholism usually results in unbalanced nutrition, as well as decreased immune function. A middle-aged adult, an older adult with wheezing induced by exercise, and a young adult vegetarian would not be at risk for community-acquired pneumonia because they have no predisposing conditions.

DIF: Cognitive Level: Comprehension/Understanding REF: Chart 33-4, p. 648

TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

MSC: Integrated Process: Nursing Process (Assessment)

25. Which is the nurses best response to an older adult client who is hesitant to take the pneumococcal vaccination and influenza vaccine in the same year?

a.

You need both injections. A risk factor for getting pneumonia is infection with influenza.

b.

Take both injections. They will protect you against respiratory problems for this year.

c.

The flu shot may protect you against influenza but not against bacteria that cause pneumonia.

d.

You should get the pneumococcal vaccination so you wont infect other people.

ANS: C

Although influenza can lead to pneumonia, and preventing influenza with a flu shot reduces the risk for a secondary pneumonia, bacterial pneumonia can be acquired without influenza as a precipitating event and can be life threatening. Getting both injections will not protect the client from respiratory problems, nor will it prevent the client from being infectious to other people.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Teaching/Learning

26. Which is a priority teaching intervention for the client who is using a nicotine patch?

a.

Abruptly discontinuing this patch can cause high blood pressure.

b.

Abruptly discontinuing this patch can cause nausea and vomiting.

c.

Smoking while using this patch increases the risk for pneumonia.

d.

Smoking while using this patch increases the risk for a heart attack.

ANS: D

Nicotine constricts blood vessels, increases mean arterial pressure, and increases afterload. Smoking while using a nicotine patch increases afterload to such an extent that the myocardium must work harder (with the coronary arteries constricted) and may cause a myocardial infarction. Abruptly discontinuing the patch will not necessarily cause hypertension or nausea and vomiting. Smoking while using the patch will not increase the risk for pneumonia.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 652

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Teaching/Learning

27. A client is admitted with left lower lung pneumonia. Which assessment finding does the nurse correlate with this condition?

a.

Expiratory wheeze on the right side

b.

Dullness to percussion on the lower left side

c.

Crepitus of the skin around the left lung

d.

Crackles heard on expiration bilaterally

ANS: B

The client with pneumonia may have dullness to percussion on the affected side. The other options are all inconsistent with pneumonia.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

28. The nurse auscultates the following lung sound in the client with pneumonia. What is the best intervention? (Click the media button to hear the audio clip.)

a.

Have the client cough and deep breathe.

b.

Prepare to administer a bronchodilator.

c.

Have the client use an incentive spirometer.

d.

Administer IV fluids.

ANS: C

The sound heard is crackles. Crackles often indicate atelectasis, which can be reversed by using an incentive spirometer. If no spirometer is available, coughing and deep breathing is the next best option. This client does not have wheezing, so bronchodilators are not indicated. IV fluids would not help atelectasis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Intervention)

29. A client has a tuberculin skin test as a pre-employment physical requirement. Which statement by the nurse is best made to the client who has the test result seen in the photograph below?

a.

Your PPD is negative. No further follow-up is necessary.

b.

You will need to have a second PPD.

c.

You will need to have titers drawn.

d.

You will need further testing.

ANS: D

The tuberculin test (Mantoux test) result is the most commonly used reliable test of TB infection. The photo shows a positive reaction. A positive reaction does not mean that active disease is present but indicates exposure to TB or the presence of inactive (dormant) disease. Conclusive evidence of TB is not provided through an examination of the chest or a chest x-ray. Only a sputum specimen will provide definitive evidence of the disease process.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

MULTIPLE RESPONSE

1. What teaching is appropriate for a client with acute rhinitis and sinusitis? (Select all that apply.)

a.

Using hot packs over the sinuses

b.

Fluid restriction

c.

Saline irrigations

d.

Staying in a dry climate

e.

Taking echinacea

f.

Antifungal medications

ANS: A, C, E

Treatment of sinusitis includes the use of broad-spectrum antibiotics (e.g., amoxicillin), analgesics for pain and fever, decongestants, steam humidification, hot and wet packs over the sinus area, and nasal saline irrigations. As complementary therapy, echinacea is recommended for the symptom of rhinitis. Antifungal medications, fluid restrictions, and staying in a dry climate are not recommended.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

2. A client enters the clinic with an acute sore throat and a temperature of 101.5 F (38.5 C). What diagnostic testing does the nurse educate the client about? (Select all that apply.)

a.

Complete blood count (CBC)

b.

Throat culture

c.

Monospot test

d.

Arterial blood gas

e.

Biopsy

f.

HIV testing

ANS: A, B, C

CBC, throat culture, and monospot testing can help to determine the causes of sore throat and fever. A biopsy is not needed. Human immune deficiency virus (HIV) testing would not be indicated unless the symptoms were a recurrent problem. Arterial blood gases would not be performed unless the client had dyspnea and a low oxygen saturation reading.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)

3. What is the best way for the nurse to decrease the risk of ventilator-associated pneumonia (VAP) in a ventilator-dependent client? (Select all that apply.)

a.

Provide prophylactic antibiotics.

b.

Provide frequent oral care.

c.

Keep the head of the bed elevated.

d.

Maintain good hand hygiene.

e.

Perform chest percussion frequently.

ANS: B, C, D

Providing frequent oral care, keeping the head of the bed elevated, and maintaining good hand hygiene are currently stated as the best ways to help prevent VAP. Prophylactic antibiotics are not recommended; neither is taking the client off the ventilator. Likewise, frequent chest percussion is not stated as an intervention to decrease VAP.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

4. A client who previously had a bacillus Calmette-Gurin (BCG) vaccine has a positive tuberculosis (TB) test. What symptoms assist in determining that the client has active disease? (Select all that apply.)

a.

Nausea

b.

Weight loss

c.

Insomnia

d.

Ankle edema

e.

Night sweats

f.

Increased urination

ANS: A, B, E

TB symptoms include nausea and weight loss, as well as night sweats. Inability to sleep and ankle edema are not typical symptoms. Increased urination also is not a typical symptom.

DIF: Cognitive Level: Comprehension/Understanding REF: pp. 654-655

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

5. A client started on therapy for tuberculosis infection is reporting nausea. What does the nurse teach this client? (Select all that apply.)

a.

Eat a diet rich in protein, iron, and vitamins.

b.

Do not drink fluids with medications.

c.

Take medications at bedtime.

d.

Space medications 12 hours apart.

e.

Take medications with milk.

f.

Take an antiemetic daily.

ANS: A, C, F

Taking the daily dose of medications at bedtime may help to decrease nausea. A well-balanced diet with foods rich in iron, protein, and vitamins C and B also helps to decrease nausea. Antiemetics are often prescribed. Drinking fluids with medications should not influence the nausea; neither should taking medications with milk. Spacing medications 12 hours apart is not recommended therapy.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration)

MSC: Integrated Process: Nursing Process (Implementation)

6. The nurse is caring for a client who is suspected of having severe acute respiratory syndrome (SARS). What actions by the nurse are most appropriate? (Select all that apply.)

a.

Wash hands when entering the clients room and use Standard Precautions.

b.

Wear a gown and goggles when entering the clients room.

c.

Teach the client to wear a mask at all times when someone is in the room.

d.

Use a disposable particulate mask respirator when the client is coughing.

e.

Keep the door to the clients room open to allow close monitoring.

f.

Place the client in a negative airflow room, if available in the facility.

ANS: B, D, F

The nurse should follow Airborne Precautions when caring for clients suspected of SARS. Wear a gown and goggles when in the room and caring for the client. Use a disposable particulate mask respirator if the client is coughing, or if particles are being aerosolized. Handwashing and Standard Precautions are not enough. The client does not have to wear a mask while others are in the room because they should be protecting themselves by using Airborne Precautions.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

7. The nurse is caring for a client who has inhalation anthrax. What nursing actions are of the highest priority? (Select all that apply.)

a.

Placing the client in an isolation room

b.

Teaching the client how to use a mask

c.

Teaching the client about long-term antibiotic therapy

d.

Using handwashing and other Standard Precautions

e.

Reporting suspected cases to the proper authorities

ANS: C, D, E

The client should not stop the drug merely because he or she has no manifestations. The client will need to be on the drug for longer than 1 month. The nurse should teach the client about long-term antibiotic therapy to help with compliance. Inhalation anthrax is not spread by person-to-person contact, so isolation would not be necessary. The client would not need a mask. Health care providers need only use handwashing and Standard Precautions. Always report inhalation anthrax to authorities because it is considered an intentional act of terrorism.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Teaching/Learning

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