Nursing Elites

1. A client has just been diagnosed with active tuberculosis. Which of the following nursing interventions should the nurse perform to prevent transmission to others?

• A. Begin drug therapy within 72 hours of diagnosis
• B. Place the client in a positive-pressure room
• C. Initiate standard precautions
• D. Place the client in a negative-pressure room

Correct answer: D

Rationale: A client diagnosed with active tuberculosis should be placed in isolation in a negative-pressure room to prevent transmission of infection to others. Placing the client in a negative-pressure room ensures that air is exhausted to the outside and received from surrounding areas, preventing tuberculin particles from traveling through the ventilation system and infecting others. Initiating standard precautions, as mentioned in choice C, is essential for infection control but is not specific to preventing transmission in the case of tuberculosis. Beginning drug therapy within 72 hours of diagnosis, as in choice A, is crucial for the treatment of tuberculosis but does not directly address preventing transmission. Placing the client in a positive-pressure room, as in choice B, is incorrect as positive-pressure rooms are used for clients with compromised immune systems to prevent outside pathogens from entering the room, which is not suitable for a client with active tuberculosis.

2. Which of the following statements best describes postural drainage as part of chest physiotherapy?

• A. Tapping on the chest wall to loosen secretions
• B. Squeezing the abdomen to increase expansion of the upper chest
• C. Using gravity to move secretions in the lung tissue
• D. Dilating the trachea to facilitate better release of secretions

Correct answer: C

Rationale: Postural drainage is a technique used in chest physiotherapy for clients with accumulated lung secretions. It involves positioning the client to utilize gravity in moving secretions from the lungs. Choice A, tapping on the chest wall, describes percussion, not postural drainage. Choice B, squeezing the abdomen, is not a correct description of postural drainage. Choice D, dilating the trachea, is not related to postural drainage but may be associated with airway clearance techniques.

3. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

• A. Weak, nonproductive cough effort
• B. Large amounts of greenish sputum
• C. Respiratory rate of 28 breaths/minute
• D. Resting pulse oximetry (SpO2) of 85%

Correct answer: A

Rationale: The correct answer is 'Weak, nonproductive cough effort.' A weak, nonproductive cough indicates that the patient is unable to clear the airway effectively, supporting the nursing diagnosis of ineffective airway clearance. In pneumonia, secretions can obstruct the airway, leading to ineffective clearance. Choices B, C, and D do not directly reflect ineffective airway clearance. Large amounts of greenish sputum (Choice B) may suggest infection or inflammation but do not specifically indicate ineffective airway clearance. The respiratory rate of 28 breaths/minute (Choice C) and a resting pulse oximetry (SpO2) of 85% (Choice D) are more indicative of impaired gas exchange or respiratory distress rather than ineffective airway clearance.

4. The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?

• A. Diarrhea
• B. Projectile vomiting
• C. Regurgitation of feedings
• D. Constipation

Correct answer: C

Rationale: Hirschsprung's disease, also known as congenital aganglionosis or aganglionic megacolon, is characterized by the absence of ganglion cells in the rectum and other parts of the affected intestine. Clinical manifestations of Hirschsprung's disease include chronic constipation with pellet-like or ribbon-like foul-smelling stools, delayed or absent passage of meconium in the neonatal period, bowel obstruction (especially in the neonatal period), abdominal pain and distention, and failure to thrive. In the case of an infant with suspected Hirschsprung's disease, regurgitation of feedings is a sign that may have led the mother to seek healthcare. This symptom can be associated with the bowel dysfunction and obstruction seen in Hirschsprung's disease. Options A, B, and D are not typically associated with Hirschsprung's disease. Diarrhea is not a common symptom, projectile vomiting is not a typical presentation, and constipation, while a symptom of the disease, is not the sign that would most likely prompt a visit to seek healthcare in an infant suspected of having Hirschsprung's disease.

5. The patient is being taught about pulmonary function testing (PFT). Which statement made by the patient indicates effective teaching?

• A. I will use my inhaler right before the test.
• B. I won't eat or drink anything 8 hours before the test.
• C. I should inhale deeply and blow out as hard as I can during the test.
• D. My blood pressure and pulse will be checked every 15 minutes after the test.

Correct answer: C

Rationale: The correct answer is 'I should inhale deeply and blow out as hard as I can during the test.' This statement indicates effective teaching because for PFT, the patient needs to inhale deeply and exhale forcefully. This maneuver helps in assessing lung function accurately. Choices A, B, and D are incorrect. Using an inhaler right before the test may alter the test results, which is not recommended. Fasting for 8 hours is not necessary for a PFT, and checking blood pressure and pulse every 15 minutes after the test is not part of the PFT procedure.

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