You are about to accomplish a 60-item examination covering the topics of Pneumonia and Pulmonary Tuberculosis. This is an NCLEX style exam that will challenge your knowledge to help you be more prepared for the test.
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NCLEX Exam: Pneumonia and Tuberculosis (60 Questions)
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NCLEX Exam: Pneumonia and Tuberculosis (60 Questions)
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1. Clients with chronic illnesses are more likely to get pneumonia when which of the following situations is present?
2. Group living
4. Severe periodontal disease
2. Which of the following pathophysiological mechanisms that occurs in the lung parenchyma allows pneumonia to develop?
3. Which of the following organisms most commonly causes community-acquired pneumonia in adults?
1. Haemiphilus influenzae
2. Klebsiella pneumoniae
3. Streptococcus pneumoniae
4. Staphylococcus aureus
4. An elderly client with pneumonia may appear with which of the following symptoms first?
5. When auscultating the chest of a client with pneumonia, the nurse would expect to hear which of the following sounds over areas of consolidation?
6. A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests?
7. A client with pneumonia develops dyspnea with a respiratory rate of 32 breaths/minute and difficulty expelling his secretions. The nurse auscultates his lung fields and hears bronchial sounds in the left lower lobe. The nurse determines that the client requires which of the following treatments first?
2. Bed rest
4. Nutritional intake
8. A client has been treated with antibiotic therapy for right lower-lobe pneumonia for 10 days and will be discharged today. Which of the following physical findings would lead the nurse to believe it is appropriate to discharge this client?
1. Continued dyspnea
2. Fever of 102*F
3. Respiratory rate of 32 breaths/minute
4. Vesicular breath sounds in right base
9. The right forearm of a client who had a purified protein derivative (PPD) test for tuberculosis is reddened and raised about 3mm where the test was given. This PPD would be read as having which of the following results?
2. Needs to be redone
10. A client with primary TB infection can expect to develop which of the following conditions?
1. Active TB within 2 weeks
2. Active TB within 1 month
3. A fever that requires hospitalization
4. A positive skin test
11. A client was infected with TB 10 years ago but never developed the disease. He’s now being treated for cancer. The client begins to develop signs of TB. This is known as which of the following types of infection?
1. Active infection
2. Primary infection
4. Tertiary infection
12. A client has active TB. Which of the following symptoms will he exhibit?
13. Which of the following diagnostic tests is definitive for TB?
1. Chest x-ray
2. Mantoux test
3. Sputum culture
4. Tuberculin test
14. A client with a positive Mantoux test result will be sent for a chest x-ray. For which of the following reasons is this done?
1. To confirm the diagnosis
2. To determine if a repeat skin test is needed
3. To determine the extent of the lesions
4. To determine if this is a primary or secondary infection
15. A chest x-ray should a client’s lungs to be clear. His Mantoux test is positive, with a 10mm if induration. His previous test was negative. These test results are possible because:
1. He had TB in the past and no longer has it.
2. He was successfully treated for TB, but skin tests always stay positive.
3. He’s a “seroconverter”, meaning the TB has gotten to his bloodstream.
4. He’s a “tuberculin converter,” which means he has been infected with TB since his last skin test.
16. A client with a positive skin test for TB isn’t showing signs of active disease. To help prevent the development of active TB, the client should be treated with isoniazid, 300 mg daily, for how long?
1. 10 to 14 days
2. 2 to 4 weeks
3. 3 to 6 months
4. 9 to 12 months
17. A client with a productive cough, chills, and night sweats is suspected of having active TB. The physician should take which of the following actions?
1. Admit him to the hospital in respiratory isolation
2. Prescribe isoniazid and tell him to go home and rest
3. Give a tuberculin test and tell him to come back in 48 hours and have it read.
4. Give a prescription for isoniazid, 300 mg daily for 2 weeks, and send him home.
18. A client is diagnosed with active TB and started on triple antibiotic therapy. What signs and symptoms would the client show if therapy is inadequate?
1. Decreased shortness of breath
2. Improved chest x-ray
3. Nonproductive cough
4. Positive acid-fast bacilli in a sputum sample after 2 months of treatment.
19. A client diagnosed with active TB would be hospitalized primarily for which of the following reasons?
1. To evaluate his condition
2. To determine his compliance
3. To prevent spread of the disease
4. To determine the need for antibiotic therapy.
20. A high level of oxygen exerts which of the following effects on the lung?
1. Improves oxygen uptake
2. Increases carbon dioxide levels
3. Stabilizes carbon dioxide levels
4. Reduces amount of functional alveolar surface area
21. A 24-year-old client comes into the clinic complaining of right-sided chest pain and shortness of breath. He reports that it started suddenly. The assessment should include which of the following interventions?
1. Auscultation of breath sounds
2. Chest x-ray
4. Electrocardiogram (ECG)
22. A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this?
23. Which of the following treatments would the nurse expect for a client with a spontaneous pneumothorax?
3. Chest tube placement
4. Hyperbaric chamber
24. Which of the following methods is the best way to confirm the diagnosis of a pneumothorax?
1. Auscultate breath sounds
2. Have the client use an incentive spirometer
3. Take a chest x-ray
4. stick a needle in the area of decreased breath sounds
25. A pulse oximetry gives what type of information about the client?
1. Amount of carbon dioxide in the blood
2. Amount of oxygen in the blood
3. Percentage of hemoglobin carrying oxygen
4. Respiratory rate
26. What effect does hemoglobin amount have on oxygenation status?
1. No effect
2. More hemoglobin reduces the client’s respiratory rate
3. Low hemoglobin levels cause reduces oxygen-carrying capacity
4. Low hemoglobin levels cause increased oxygen-carrying capacity.
27. Which of the following statements best explains how opening up collapsed alveoli improves oxygenation?
1. Alveoli need oxygen to live
2. Alveoli have no effect on oxygenation
3. Collapsed alveoli increase oxygen demand
4. Gaseous exchange occurs in the alveolar membrane.
28. Continuous positive airway pressure (CPAP) can be provided through an oxygen mask to improve oxygenation in hypoxic patients by which of the following methods?
1. The mask provides 100% oxygen to the client.
2. The mask provides continuous air that the client can breathe.
3. The mask provides pressurized oxygen so the client can breathe more easily.
4. The mask provides pressurized at the end of expiration to open collapsed alveoli.
29. Which of the following best describes pleural effusion?
1. The collapse of alveoli
2. The collapse of bronchiole
3. The fluid in the alveolar space
4. The accumulation of fluid between the linings of the pleural space.
30. If a pleural effusion develops, which of the following actions best describes how the fluid can be removed from the pleural space and proper lung status restored?
1. Inserting a chest tube
2. Performing thoracentesis
3. Performing paracentesis
4. Allowing the pleural effusion to drain by itself.
31. A comatose client needs a nasopharyngeal airway for suctioning. After the airway is inserted, he gags and coughs. Which action should the nurse take?
1. Remove the airway and insert a shorter one.
2. Reposition the airway.
3. Leave the airway in place until the client gets used to it.
4. Remove the airway and attempt suctioning without it.
32. An 87-year-old client requires long-term ventilator therapy. He has a tracheostomy in place and requires frequent suctioning. Which of the following techniques is correct?
1. Using intermittent suction while advancing the catheter.
2. Using continuous suction while withdrawing the catheter.
3. Using intermittent suction while withdrawing the catheter.
4. Using continuous suction while advancing the catheter.
33. A client’s ABG analysis reveals a pH of 7.18, PaCO2 of 72 mm Hg, PaO2 of 77 mm Hg, and HCO3- of 24 mEq/L. What do these values indicate?
1. Metabolic acidosis
2. Respiratory alkalosis
3. Metabolic alkalosis
4. Respiratory acidosis
34. A police officer brings in a homeless client to the ER. A chest x-ray suggests he has TB. The physician orders an intradermal injection of 5 tuberculin units/0.1 ml of tuberculin purified derivative. Which needle is appropriate for this injection?
1. 5/8” to ½” 25G to 27G needle.
2. 1” to 3” 20G to 25G needle.
3. ½” to 3/8” 26 or 27G needle.
4. 1” 20G needle.
35. A 76-year old client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no signs of respiratory distress. Which of the following is a normal physiologic change related to aging?
1. Increased elastic recoil of the lungs
2. Increased number of functional capillaries in the alveoli
3. Decreased residual volume
4. Decreased vital capacity.
36. A 79-year-old client is admitted with pneumonia. Which nursing diagnosis should take priority?
1. Acute pain related to lung expansion secondary to lung infection
2. Risk for imbalanced fluid volume related to increased insensible fluid losses secondary to fever.
3. Anxiety related to dyspnea and chest pain.
4. Ineffective airway clearance related to retained secretions.
37. A community health nurse is conducting an educational session with community members regarding TB. The nurse tells the group that one of the first symptoms associated with TB is:
1. A bloody, productive cough
2. A cough with the expectoration of mucoid sputum
3. Chest pain
38. A nurse evaluates the blood theophylline level of a client receiving aminophylline (theophylline) by intravenous infusion. The nurse would determine that a therapeutic blood level exists if which of the following were noted in the laboratory report?
1. 5 mcg/mL
2. 15 mcg/mL
3. 25 mcg/mL
4. 30 mcg/mL
39. Isoniazid (INH) and rifampin (Rifadin) have been prescribed for a client with TB. A nurse reviews the medical record of the client. Which of the following, if noted in the client’s history, would require physician notification?
40. A client is experiencing confusion and tremors is admitted to a nursing unit. An initial ABG report indicates that the PaCO2 level is 72 mm Hg, whereas the PaO2 level is 64 mm Hg. A nurse interprets that the client is most likely experiencing:
1. Carbon monoxide poisoning
2. Carbon dioxide narcosis
3. Respiratory alkalosis
4. Metabolic acidosis
41. A client who is HIV+ has had a PPD skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interprets the results as:
4. The need for repeat testing.
42. A nurse is caring for a client diagnosed with TB. Which assessment, if made by the nurse, would not be consistent with the usual clinical presentation of TB and may indicate the development of a concurrent problem?
1. Nonproductive or productive cough
2. Anorexia and weight loss
3. Chills and night sweats
4. High-grade fever
43. A nurse is teaching a client with TB about dietary elements that should be increased in the diet. The nurse suggests that the client increase intake of:
1. Meats and citrus fruits
2. Grains and broccoli
3. Eggs and spinach
4. Potatoes and fish
44. Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply.
1. Auscultation of breath sounds
2. Auscultation of bowel sounds
3. Presence of chest pain.
4. Presence of peripheral edema
5. Color of nail beds
45. A client with pneumonia has a temperature of 102.6*F (39.2*C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care?
1. Position changes q4h
2. Nasotracheal suctioning to clear secretions
3. Frequent linen changes
4. Frequent offering of a bedpan.
46. The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following?
1. Decreased cardiac output
2. Pleural effusion
3. Inadequate peripheral circulation
4. Decreased oxygenation of the blood.
47. Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia?
48. A client with pneumonia has a temperature ranging between 101* and 102*F and periods of diaphoresis. Based on this information, which of the following nursing interventions would be a priority?
1. Maintain complete bedrest
2. Administer oxygen therapy
3. Provide frequent linen changes.
4. Provide fluid intake of 3 L/day
49. Which of the following would be an appropriate expected outcome for an elderly client recovering from bacterial pneumonia?
1. A respiratory rate of 25 to 30 breaths per minute
2. The ability to perform ADL’s without dyspnea
3. A maximum loss of 5 to 10 pounds of body weight
4. Chest pain that is minimized by splinting the ribcage.
50. Which of the following symptoms is common in clients with TB?
1. Weight loss
2. Increased appetite
3. Dyspnea on exertion
4. Mental status changes
51. The nurse obtains a sputum specimen from a client with suspected TB for laboratory study. Which of the following laboratory techniques is most commonly used to identify tubercle bacilli in sputum?
1. Acid-fast staining
2. Sensitivity testing
3. Agglutination testing
4. Dark-field illumination
52. Which of the following antituberculous drugs can cause damage to the eighth cranial nerve?
3. Para-aminosalicylic acid
4. Ethambutol hydrochloride
53. The client experiencing eighth cranial nerve damage will most likely report which of the following symptoms?
2. Facial paralysis
3. Impaired vision
4. Difficulty swallowing
54. Which of the following family members exposed to TB would be at highest risk for contracting the disease?
1. 45-year-old mother
2. 17-year-old daughter
3. 8-year-old son
4. 76-year-old grandmother
55. The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurses instructions? Select all that apply.
1. “I will need to dispose of my old clothing when I return home.”
2. “I should always cover my mouth and nose when sneezing.”
3. “It is important that I isolate myself from family when possible.”
4. “I should use paper tissues to cough in and dispose of them properly.”
5. “I can use regular plate and utensils whenever I eat.”
56. A client has a positive reaction to the PPD test. The nurse correctly interprets this reaction to mean that the client has:
1. Active TB
2. Had contact with Mycobacterium tuberculosis
3. Developed a resistance to tubercle bacilli
4. Developed passive immunity to TB.
57. INH treatment is associated with the development of peripheral neuropathies. Which of the following interventions would the nurse teach the client to help prevent this complication?
1. Adhere to a low cholesterol diet
2. Supplement the diet with pyridoxine (vitamin B6)
3. Get extra rest
4. Avoid excessive sun exposure.
58. The nurse should include which of the following instructions when developing a teaching plan for clients receiving INH and rifampin for treatment for TB?
59. The public health nurse is providing follow-up care to a client with TB who does not regularly take his medication. Which nursing action would be most appropriate for this client?
1. Ask the client’s spouse to supervise the daily administration of the medications.
2. Visit the clinic weekly to ask him whether he is taking his medications regularly.
3. Notify the physician of the client’s non-compliance and request a different prescription.
4. Remind the client that TB can be fatal if not taken properly.
60. The Causative agent of Tuberculosis is said to be:
1. Mycobacterium Tuberculosis
2. Hansen’s Bacilli
3. Bacillus Anthracis
4. Group A Beta Hemolytic Streptococcus
Answers and Rationale
1. Answer: 2. Group living
Clients with chronic illnesses generally have poor immune systems. Often, residing in group living situations increases the chance of disease transmission.
2. Answer: 4. Inflammation
The common feature of all type of pneumonia is an inflammatory pulmonary response to the offending organism or agent. Atelectasis and bronchiectasis indicate a collapse of a portion of the airway that doesn’t occur in pneumonia. An effusion is an accumulation of excess pleural fluid in the pleural space, which may be a secondary response to pneumonia.
3. Answer: 3. Streptococcus pneumoniae
Pneumococcal or streptococcal pneumonia, caused by streptococcus pneumoniae, is the most common cause of community-acquired pneumonia. H. influenzae is the most common cause of infection in children. Klebsiella species is the most common gram-negative organism found in the hospital setting. Staphylococcus aureus is the most common cause of hospital-acquired pneumonia.
4. Answer: 1. Altered mental status and dehydration
Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are common symptoms of pneumonia, but elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response.
5. Answer: 1. Bronchial
Chest auscultation reveals bronchial breath sounds over areas of consolidation. Bronchovesicular are normal over midlobe lung regions, tubular sounds are commonly heard over large airways, and vesicular breath sounds are commonly heard in the bases of the lung fields.
6. Answer: 4. sputum culture and sensitivity
Sputum C & S is the best way to identify the organism causing the pneumonia. Chest x-ray will show the area of lung consolidation. ABG analysis will determine the extent of hypoxia present due to the pneumonia, and blood cultures will help determine if the infection is systemic.
7. Answer: 3. Oxygen
The client is having difficulty breathing and is probably becoming hypoxic. As an emergency measure, the nurse can provide oxygen without waiting for a physicians order. Antibiotics may be warranted, but this isn’t a nursing decision. The client should be maintained on bedrest if he is dyspneic to minimize his oxygen demands, but providing additional will deal more immediately with his problem. The client will need nutritional support, but while dyspneic, he may be unable to spare the energy needed to eat and at the same time maintain adequate oxygenation.
8. Answer: 4. Vesicular breath sounds in right base
If the client still has pneumonia, the breath sounds in the right base will be bronchial, not the normal vesicular breath sounds. If the client still has dyspnea, fever, and increased respiratory rate, he should be examined by the physician before discharge because he may have another source of infection or still have pneumonia.
9. Answer: 3. Negative
This test would be classed as negative. A 5 mm raised area would be a positive result if a client was HIV+ or had recent close contact with someone diagnosed with TB. Indeterminate isn’t a term used to describe results of a PPD test. If the PPD is reddened and raised 10mm or more, it’s considered positive according to the CDC.
10. Answer: 4. A positive skin test
A primary TB infection occurs when the bacillus has successfully invaded the entire body after entering through the lungs. At this point, the bacilli are walled off and skin tests read positive. However, all but infants and immunosuppressed people will remain asymptomatic. The general population has a 10% risk of developing active TB over their lifetime, in many cases because of a break in the body’s immune defenses. The active stage shows the classic symptoms of TB: fever, hemoptysis, and night sweats.
11. Answer: 1. Active infection
Some people carry dormant TB infections that may develop into active disease. In addition, primary sites of infection containing TB bacilli may remain inactive for years and then activate when the client’s resistance is lowered, as when a client is being treated for cancer. There’s no such thing as tertiary infection, and superinfection doesn’t apply in this case.
12. Answer: 2. Chills, fever, night sweats, and hemoptysis
Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain may be present from coughing, but isn’t usual. Clients with TB typically have low-grade fevers, not higher than 102*F. Nausea, headache, and photophobia aren’t usual TB symptoms.
13. Answer: 3. Sputum culture
The sputum culture for Mycobacterium tuberculosis is the only method of confirming the diagnosis. Lesions in the lung may not be big enough to be seen on x-ray. Skin tests may be falsely positive or falsely negative.
14. Answer: 3. To determine the extent of the lesions
If the lesions are large enough, the chest x-ray will show their presence in the lungs. Sputum culture confirms the diagnosis. There can be false-positive and false-negative skin test results. A chest x-ray can’t determine if this is a primary or secondary infection.
15. Answer: 4. He’s a “tuberculin converter,” which means he has been infected with TB since his last skin test.
A tuberculin converter’s skin test will be positive, meaning he has been exposed to an infected with TB and now has a cell-mediated immune response to the skin test. The client’s blood and x-ray results may stay negative. It doesn’t mean the infection has advanced to the active stage. Because his x-ray is negative, he should be monitored every 6 months to see if he develops changes in his x-ray or pulmonary examination. Being a seroconverter doesn’t mean the TB has gotten into his bloodstream; it means it can be detected by a blood test.
16. Answer: 4. 9 to 12 months
Because of the increased incidence of resistant strains of TB, the disease must be treated for up to 24 months in some cases, but treatment typically lasts for 9-12 months. Isoniazid is the most common medication used for the treatment of TB, but other antibiotics are added to the regimen to obtain the best results.
17. Answer: 1. Admit him to the hospital in respiratory isolation
The client is showing s/s of active TB and because of a productive cough is highly contagious. He should be admitted to the hospital, placed in respiratory isolation, and three sputum cultures should be obtained to confirm the diagnosis. He would most likely be given isoniazid and two or three other antitubercular antibiotics until the diagnosis is confirmed, then isolation and treatment would continue if the cultures were positive for TB. After 7 to 10 days, three more consecutive sputum cultures will be obtained. If they’re negative, he would be considered non-contagious and may be sent home, although he’ll continue to take the antitubercular drugs for 9 to 12 months.
18. Answer: 4. Positive acid-fast bacilli in a sputum sample after 2 months of treatment.
Continuing to have acid-fast bacilli in the sputum after 2 months indicated continued infection.
19. Answer: 3. To prevent spread of the disease
The client with active TB is highly contagious until three consecutive sputum cultures are negative, so he’s put in respiratory isolation in the hospital.
20. Answer: 4. Reduces amount of functional alveolar surface area
Oxygen toxicity causes direct pulmonary trauma, reducing the amount of alveolar surface area available for gaseous exchange, which results in increased carbon dioxide levels and decreased oxygen uptake.
21. Answer: 1. Auscultation of breath sounds
Because the client is short of breath, listening to breath sounds is a good idea. He may need a chest x-ray and an ECG, but a physician must order these tests. Unless a cardiac source for the client’s pain is identified, he won’t need an echocardiogram.
22. Answer: 4. Spontaneous pneumothorax
A spontaneous pneumothorax occurs when the client’s lung collapses, causing an acute decrease in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. An asthma attack would show wheezing breath sounds, and bronchitis would have rhonchi. Pneumonia would have bronchial breath sounds over the area of consolidation.
23. Answer: 3. Chest tube placement
The only way to re-expand the lung is to place a chest tube on the right side so the air in the pleural space can be removed and the lung re-expanded.
24. Answer: 3. Take a chest x-ray
A chest x-ray will show the area of collapsed lung if pneumothorax is present as well as the volume of air in the pleural space. Listening to breath sounds won’t confirm a diagnosis. An IS is used to encourage deep breathing. A needle thoracostomy is done only in an emergency and only by someone trained to do it.
25. Answer: 3. Percentage of hemoglobin carrying oxygen
The pulse oximeter determines the percentage of hemoglobin carrying oxygen. This doesn’t ensure that the oxygen being carried through the bloodstream is actually being taken up by the tissue.
26. Answer: 3. Low hemoglobin levels cause reduces oxygen-carrying capacity
Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. More hemoglobin will increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood. If the client has been tachypneic during exertion, or even at rest, because oxygen demand is higher than the available oxygen content, then an increase in hemoglobin may decrease the respiratory rate to normal levels.
27. Answer: 4. Gaseous exchange occurs in the alveolar membrane.
Gaseous exchange occurs in the alveolar membrane, so if the alveoli collapse, no exchange occurs, Collapsed alveoli receive oxygen, as well as other nutrients, from the bloodstream. Collapsed alveoli have no effect on oxygen demand, though by decreasing the surface area available for gas exchange, they decrease oxygenation of the blood.
28. Answer: 3. The mask provides pressurized oxygen so the client can breathe more easily.
The mask provides pressurized oxygen continuously through both inspiration and expiration. The mask can be set to deliver any amount of oxygen needed. By providing the client with pressurized oxygen, the client has less resistance to overcome in taking his next breath, making it easier to breathe. Pressurized oxygen delivered at the end of expiration is positive end-expiratory pressure (PEEP), not continuous positive airway pressure.
29. Answer: 4. The accumulation of fluid between the linings of the pleural space.
The pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatics. Any condition that interferes with either the secretion or drainage of this fluid will lead to a pleural effusion.
30. Answer: 2. Performing thoracentesis
Performing thoracentesis is used to remove excess pleural fluid. The fluid is then analyzed to determine if it’s transudative or exudative. Transudates are substances that have passed through a membrane and usually occur in low protein states. Exudates are substances that have escaped from blood vessels. They contain an accumulation of cells and have a high specific gravity and a high lactate dehydrogenase level. Exudates usually occur in response to a malignancy, infection, or inflammatory process. A chest tube is rarely necessary because the amount of fluid typically isn’t large enough to warrant such a measure. Pleural effusions can’t drain by themselves.
31. Answer: 1. Remove the airway and insert a shorter one.
If a client gags or coughs after nasopharyngeal airway placement, the tube may be too long. The nurse should remove it and insert a shorter one. Simply repositioning the airway won’t solve the problem. The client won’t get used to the tube because it’s the wrong size. Suctioning without a nasopharyngeal airway causes trauma to the natural airway.
32. Answer: 3. Using intermittent suction while withdrawing the catheter.
Intermittent suction should be applied during catheter withdrawal. To prevent hypoxia, suctioning shouldn’t last more than 10-seconds at a time. Suction shouldn’t be applied while the catheter is being advanced.
33. Answer: 4. Respiratory acidosis
34. Answer: 3. ½” to 3/8” 26 or 27G needle.
Intradermal injections like those used in TN skin tests are administered in small volumes (usually 0.5 ml or less) into the outer skin layers to produce a local effect. A TB syringe with a ½” to 3/8” 26G or 27G needle should be inserted about 1/8” below the epidermis.
35. Answer: 4. Decreased vital capacity.
Reduction in VC is a normal physiologic change in the older adult. Other normal physiologic changes include decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increase is residual volume.
36. Answer: 4. Ineffective airway clearance related to retained secretions.
Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction may cause an outpouring of exudate into the alveolar spaces, leading to an ineffective airway clearance related to retained secretions.
37. Answer: 2. A cough with the expectoration of mucoid sputum
One of the first pulmonary symptoms includes a slight cough with the expectoration of mucoid sputum.
38. Answer: 2. 15 mcg/mL
The therapeutic theophylline blood level range from 10-20 mcg/mL.
39. Answer: 3. Hepatitis B
Isoniazid and rifampin are contraindicated in clients with acute liver disease or a history of hepatic injury.
40. Answer: 2. Carbon dioxide narcosis
Carbon dioxide narcosis is a condition that results from extreme hypercapnia, with carbon dioxide levels in excess of 70 mm Hg. The client experiences symptoms such as confusion and tremors, which may progress to convulsions and possible coma.
41. Answer: 1. Positive
The client with HIV+ status is considered to have positive results on PPD skin test with an area greater than 5-mm of induration. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client.
42. Answer: 4. High-grade fever
The client with TB usually experiences cough (non-productive or productive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.
43. Answer: 1. Meats and citrus fruits
The nurse teaches the client with TB to increase intake of protein, iron, and vitamin C.
44. Answer: 1, 3, 5.
A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.
45. Answer: 3. Frequent linen changes
Frequent linen changes are appropriate for this client because of diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the client’s productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario.
46. Answer: 4. Decreased oxygenation of the blood.
A client with pneumonia has less lung surface available for the diffusion of gases because of the inflammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation.
47. Answer: 3. Irritability
Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more pronounced, the client may become confused and combative. Coma is a late clinical manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia.
48. Answer: 4. Provide fluid intake of 3 L/day
A fluid intake of at least 3 L/day should be provided to replace any fluid loss occurring as a result the fever and diaphoresis; this is a high-priority intervention.
49. Answer: 2. The ability to perform ADL’s without dyspnea
An expected outcome for a client recovering from pneumonia would be the ability to perform ADL’s without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/minute indicates the client is experiencing tachypnea, which would not be expected on recovery. A weight loss of 5-10 pounds is undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain.
50. Answer: 1. Weight loss
TB typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-grade fever, and night sweats.
51. Answer: 1. Acid-fast staining
The most commonly used technique to identify tubercle bacilli is acid-fast staining. The bacilli have a waxy surface, which makes them difficult to stain in the lab. However, once they are stained, the stain is resistant to removal, even with acids. Therefore, tubercle bacilli are often called acid-fast bacilli.
52. Answer: 1. Streptomycin
Streptomycin is an aminoglycoside, and eight cranial nerve damage (ototoxicity) is a common side effect from aminoglycosides.
53. Answer: 1. Vertigo
The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for hearing and equilibrium. Streptomycin can damage this nerve.
54. Answer: 4. 76-year-old grandmother
Elderly persons are believed to be at higher risk for contracting TB because of decreased immunocompetence. Other high-risk populations in the US include the urban poor, AIDS, and minority groups.
55. Answer: 2, 4, 5.
56. Answer: 2. Had contact with Mycobacterium tuberculosis
A positive PPD test indicates that the client has been exposed to tubercle bacilli. Exposure does not necessarily mean that active disease exists.
57. Answer: 2. Supplement the diet with pyridoxine (vitamin B6)
INH competes with the available vitamin B6 in the body and leaves the client at risk for development of neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed.
58. Answer: 4. Limit alcohol intake
INH and rifampin are hepatotoxic drugs. Clients should be warned to limit intake of alcohol during drug therapy. Both drugs should be taken on an empty stomach. If antacids are needed for GI distress, they should be taken 1 hour before or 2 hours after these drugs are administered. Clients should not double the dosage of these drugs because of their potential toxicity. Clients taking INH should avoid foods that are rich in tyramine, such as cheese and dairy products, or they may develop hypertension.
59. Answer: 1. Ask the client’s spouse to supervise the daily administration of the medications.
Directly observed therapy (DOT) can be implemented with clients who are not compliant with drug therapy. In DOT, a responsible person, who may be a family member or a health care provider, observes the client taking the medication. Visiting the client, changing the prescription, or threatening the client will not ensure compliance if the client will not or cannot follow the prescribed treatment.
60. Answer: 1. Mycobacterium Tuberculosis
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