The health care provider writes an order for bacteriologic
testing for a patient who has a positive tuberculosis skin test.
Which action should the nurse take
Teach about the reason for the blood tests.
Schedule an appointment for a chest x-ray.
Teach about the need to get sputum specimens for 2 to 3
consecutive days.
Instruct the patient to expectorate three specimens as soon as
possible.
The nurse plans to provide preoperative teaching to an alert
older man who has hearing and vision deficits. His wife usually
answers most questions that are directed to the patient. Which
action should the nurse take when doing the teaching
Use printed materials for instruction so that the patient will have
more time to review the material.
Direct the teaching toward the wife because she is the obvious
support and caregiver for the patient.
Provide additional time for the patient to understand
preoperative instructions and carry out procedures.
Ask the patient's wife to wait in the hall in order to focus
preoperative teaching with the patient himself.
"A little swelling around my lips and face is okay."
,Angioedema occurring with angiotensin-converting enzyme
(ACE) inhibitor therapy is an indication that the ACE inhibitor
should be discontinued. The patient should be taught that if any
swelling of the face or oral mucosa occurs, the health care
provider should be immediately notified because this could be
life threatening. The other patient statements indicate that the
patient has an accurate understanding of ACE inhibitor therapy.
Correct Answers The nurse has just finished teaching a
hypertensive patient about the newly prescribed ramipril
(Altace). Which patient statement indicates that more teaching is
needed
"A little swelling around my lips and face is okay."
"The medication may not work as well if I take any aspirin."
"The doctor may order a blood potassium level occasionally."
"I will call the doctor if I notice that I have a frequent cough."
"Can you tell me what it is that makes you think you will die so
soon" Correct Answers A patient with newly diagnosed lung
cancer tells the nurse, "I don't think I'm going to live to see my
next birthday." Which response by the nurse is best
"Would you like to talk to the hospital chaplain about your
feelings"
"Can you tell me what it is that makes you think you will die so
soon"
"Are you afraid that the treatment for your cancer will not be
effective"
"Do you think that taking an antidepressant medication would be
helpful"
,"Have you been consistently taking your medications"
Sudden withdrawal of antihypertensive medications can cause
rebound hypertension and hypertensive crisis. Although many
over-the-counter medications can cause hypertension,
antihistamines and acetaminophen do not increase BP. Stressful
events will increase BP but not usually to the level seen in this
patient. Correct Answers A patient with a history of
hypertension treated with a diuretic and an angiotensin-
converting enzyme (ACE) inhibitor arrives in the emergency
department complaining of a severe headache and nausea and
has a blood pressure (BP) of 238/118 mm Hg. Which question
should the nurse ask first
"Did you take any acetaminophen (Tylenol) today"
"Have you been consistently taking your medications"
"Have there been any recent stressful events in your life"
"Have you recently taken any antihistamine medications"
"Have you received the bacille Calmette-Guérin (BCG) vaccine
for TB"
Patients who have received the BCG vaccine will have a
positive Mantoux test. Another method for screening (such as a
chest x-ray) will need to be used in determining whether the
patient has a TB infection. The other information also may be
valuable but is not as pertinent to the decision about doing TB
skin testing. Correct Answers The 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
, "Is there any family history of TB"
"How long have you lived in the United States"
"Do you take any over-the-counter (OTC) medications"
"Have you received the bacille Calmette-Guérin (BCG) vaccine
for TB"
"How much alcohol do you drink in an average week" Correct
Answers A nurse obtains a health history from a patient who
has a 35 pack-year smoking history. The patient complains of
hoarseness and tightness in the throat and difficulty swallowing.
Which question is most important for the nurse to ask
"How much alcohol do you drink in an average week"
"Do you have a family history of head or neck cancer"
"Have you had frequent streptococcal throat infections"
"Do you use antihistamines for upper airway congestion"
"I can use my nasal decongestant spray until the congestion is all
gone." Correct Answers The nurse discusses management of
upper respiratory infections (URI) with a patient who has acute
sinusitis. Which statement by the patient indicates that
additional teaching is needed
"I can take acetaminophen (Tylenol) to treat my discomfort."
"I will drink lots of juices and other fluids to stay well
hydrated."
"I can use my nasal decongestant spray until the congestion is all
gone."
"I will watch for changes in nasal secretions or the sputum that I
cough up."
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