A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take?
a. Position the patient so that the left chest is dependent.
b. Tape a nonporous dressing on three sides over the chest wound.
c. Cover the sucking chest wound firmly with an occlusive dressing.
d. Keep the head of the patient's bed at no more than 30 degrees elevation.
Question 2The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?
a. Is there any family history of TB?
b. How long have you lived in the United States?
c. Do you take any over-the-counter (OTC) medications?
d. Have you received the bacille Calmette-Gurin (BCG) vaccine for TB?
Question 3The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?
a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled
b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes
d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2 F (37.8 C)
Question 4A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute.
Which action should the nurse take first?
a. Administer anticoagulant drug therapy.
b. Notify the patient's health care provider.
c. Prepare patient for a spiral computed tomography (CT).
d. Elevate the head of the bed to a semi-Fowler's position.
Question 5The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?
a. UAP splint the patient's chest during coughing.
b. UAP assist the patient to ambulate to the bathroom.
c. UAP help the patient to a bedside chair for meals.
d. UAP lower the head of the patient's bed to 15 degrees.
Question 6A patient with pneumonia has a fever of 101.4 F (38.6 C), a nonproductive cough, and an oxygen saturation of 88. The patient complains of weakness, fatigue, and needs assistance to get out of bed.
Which nursing diagnosis should the nurse assign as the highest priority?
a. Hyperthermia related to infectious illness
b. Impaired transfer ability related to weakness
c. Ineffective airway clearance related to thick secretions
d. Impaired gas exchange related to respiratory congestion
Question 7A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider?
a. The Mantoux test had an induration of 7 mm.
b. The chest-x-ray showed infiltrates in the lower lobes.
c. The patient is being treated with antiretrovirals for HIV infection.
d. The patient has a cough that is productive of blood-tinged mucus.
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