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, ...
NURS 309 Quiz 8 (Chap 20, 31) RESP 2 questions
with correct answers
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?" Correct Answer-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. Correct Answer-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 Correct
Answer-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 Correct Answer-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 Correct Answer-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
Correct Answer-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" Correct Answer-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" Correct Answer-B
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