1. Nurse admits Raymond to private room. Nurse puts on mask before admission process. Raymond tells the nurse that his significant other is downstairs and he would like for him to stay in the room with him.
How should the nurse respond?
A. "your HCP wants you to get some rest"
B. "he may stay, ...
1. Nurse admits Raymond to private room. Nurse puts on mask before admission process.
Raymond tells the nurse that his significant other is downstairs and he would like for him to stay
in the room with him.
How should the nurse respond?
A. "your HCP wants you to get some rest"
B. "he may stay, but only after we have the results of his tuberculin skin test"
C. "He may stay, but he needs to wear a mask"
D. "you dont want to risk infecting your significant other with TB, do you?" - ANS C
2. Raymond's significant other arrives. Raymond wants to know why a mask is necessary for
people entering his room.
What teaching should the nurse implement?
A. explain use of private room and mobile high-efficiency particle filters placed in the room
B. explain that the TB organism is most often spread through the air
C. tell Raymond that TB will not spread to others and everything will be okay if the mask is worn
D. tell Raymond that masks are required for those persons who do not agree to be vaccinated
with BCG vaccine. - ANS B
3. The UAP asks why Raymond could not be in an empty semiprivate room closer to the nurse's
station so the staff would not have to walk so far to provide care.
What information should the nurse provide to the UAP on infection control practices?
A. The client needs to be at the end of the hall because he requires privacy
B. The implementation of airborne precautions for possibly TB requires a private, negative
pressure room assignment
C. A private room is required to implement contact precautions for possible TB
D. The client needs to be at the end of the hall for confidentiality - ANS B
4. The nurse notices the UAP about to enter Raymond's room to deliver a meal tray without
wearing any protective apparel.
What information should the nurse provide to the UAP?
A. A mask is required for healthcare workers entering the room of someone suspected of having
active TB
B. Wearing a mask, gown, and gloves is required for healthcare workers entering Raymond's
room for any reason
C. The UAP will only be in the room for a brief moment to deliver the tray so no intervention is
needed by the nurse
,D. Non-sterile gloves are necessary to deliver the meal and prevent the spread of TB - ANS
A
5. An acid-fast bacilli (AFB) stain is part of the initial admission prescriptions. Early morning
sputum specimens will be collected for 3 consecutive days and sent to the lab.
Which tasks may the nurse delegate to the UAP? (Select all that apply)
A. have UAP tell Raymond that the specimen must be collected in the early morning
B. Provide Raymond with three sterile specimen cups at his bedside.
C. Allow the UAP to teach the client how to cough to obtain sputum from deep in the bronchi
D. Document the time and date that each sputum specimen was collected
E. Instruct the UAP to assess Raymond's ability to expectorate the sputum specimen - ANS
A, B, D
6. Raymond is scheduled for several activities the following morning.
What activity should Raymond perform first upon wakening?
A. Eat nutritionally dense, early morning snack sent from food services department
B. Obtain the first of three sputum specimens for laboratory testing
C. Take a shower and get ready to go to radiology for a chest X-ray.
D. Weigh to determine if weight loss from the disease is continuing - ANS B
9. The nurse creates a plan of care for Raymond. The nursing diagnosis of Knowledge Deficit is
used to describe what is needed during client education sessions with Raymond.
Which statements by Raymond indicates he understands why he is at risk for TB? (select all
that apply)
A. "I realize my helper T cells are diminished from HIV. Those are the cells needed to fight TB"
B. "I may get TB because my viral load count is diminished"
C. "I am at risk for developing TB because I was born with a low number of helper T cells"
D. "I realize I am at risk for acquiring TB because I used intravenous drugs in the past"
E. "I guess living in that homeless shelter increased my chances of getting TB" - ANS A, E
After 3 days, nurse receives results from Raymond's TB skin test that was administered at his
HCP's office. Even though Raymond's reaction to the TB test measures only 5mm in diameter,
the HCP documents a positive test result. A new graduate nurse finds this confusing. New grad
thought that a 10mm induration was the minimum size for a positive reading and asks the nurse
preceptor for clarification.
How should the nurse preceptor respond?
A. "This confuses me too. I think we need to consult with the HCP"
B. "That is not always true. A 5mm induration is considered positive for TB in a person with HIV"
C. "It may be that you are confusing induration with inflammation in skin testing results"
D. "Let's ask the nurse practitioner who specializes in caring for clients who are HIV positive" -
ANS B
, 13. Raymond's HCP has also prescribes the anti-TB regiment of
rifabutin/isoniazid/pyrazinamide/ethambutol. What information is important to teach Raymond
about the use of rifabutin/isoniazid/pyrazinamide/ethambutol? (select all that apply)
A. Rifabutin stains urine, stool, saliva, sweat, and tears reddish-orange
B. Liver function tests should be routinely conducted and monitored
C. There is no need to wear sunscreen when exposed to sunlight while taking
rifabutin/isoniazid/pyrazinamide
D. Visual disturbances related to ethambutol therapy may develop during therapy, but may
resolve once treatment is discontinued
E. Rifampin/isoniazid/pyrazinamide has been known to cure HIV within a few months of taking it
- ANS A, B, D
14. What is the priority nursing diagnosis for Raymond at this time?
A. Risk for new opportunistic infections related to decreased immune function
B. Social isolation related to worsening of condition
C. Imbalanced nutrition, less than body requirements related to medication side effects
D. Fatigue related to altered body chemistry - ANS A
16. Which assessment finding by the nurse would be indicative of oral candidiasis, a common
secondary infection in persons with compromised immune systems?
A. blisters on tongue or oral mucosa
B. inflammation of gums
C. painless white lesions on lateral surface of the tongue
D. white-yellow patches on the tongue or oral mucosa - ANS D
17. What instruction should the nurse give Raymond about the use of liquid nystatin (Nyamyc)?
A. place all of the suspension in the mouth, then swish and swallow immediately
B. sip the suspension over 5 minutes, swishing and swallowing after each sip
C. place the suspension in the mouth, then swish for several minutes before swallowing
D. use the applicator to paint the medication on the infected sites and swallow the remaining
dose - ANS C
18. To achieve the goal of improving Raymond's nutrition, the nurse should perform which
nursing intervention? (select all that apply)
A. request a dietary consultation for Raymond to better assess Raymond's nutritional status and
food preferences
B. Request a prescription for total parenteral nutrition
C. Monitor for oral thrush and diarrhea
D. Instruct Raymond to focus on breakfast, the most important meal of the day
E. Weigh daily and record signs of wasting syndrome - ANS A, C, E
19. Since Raymond now has thrush, in addition to fatigue and anorexia, which food best
contributes to improving Raymond's nutrition?
A. Broiled steak
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