A nurse is assisting with discharge teaching for a client who requires oropharyngeal suctioning at home. The nurse should ensure that which of the following equipment is available for use at home?

Oropharyngeal airway

Water-soluble lubricant

Yankauer catheter

Sterile gloves

Answer and Explanation

The Correct Answer is C

Yankauer catheter. A Yankauer catheter is a suction device used for oral suctioning. It is important for this client to have access to a Yankauer catheter for safe and effective suctioning of secretions from the mouth.

Option A is incorrect because an Oropharyngeal airway is used to maintain or open the airway.

Option B is incorrect because the water-soluble lubricant is used for lubricating the suction catheter during suctioning.

Option D is incorrect because sterile gloves are not routinely needed for suctioning.

Reasons why the other options are not answered: Option A: An oropharyngeal airway is not used for suctioning but is used to maintain an open airway in an unconscious patient. Option B: Water-soluble lubricant is used for lubricating the suction catheter during suctioning. Option D: Sterile gloves are not routinely needed for suctioning.

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Correct Answer is D

Explanation

Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease.

The other choices are not correct because:

- Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.

- Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.

- Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.

A. Temperature 37.3° C (99.1° F) B. WBC Count 9,000/mm3 C. Changed mental status D. Diminished reflexes

Correct Answer is C

Explanation

A bladder infection can lead to confusion or other changes in mental status, especially in older adults. A normal temperature and WBC count do not necessarily indicate a bladder infection. Diminished reflexes are not typically associated with a bladder infection.

A: A temperature of 37.3° C (99.1° F) is within the normal range and does not necessarily indicate a bladder infection.

B: A WBC count of 9,000/mm3 is within the normal range and does not necessarily indicate a bladder infection.

D: Diminished reflexes are not typically associated with a bladder infection.

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A nurse is assisting with discharge teaching for a client who requires oropharyngeal suctioning at home. The nurse should ensure that which of the following equipment is available for use at home?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with care for a client who received a tuberculin skin test 72 hr ago. When collecting data from the test site, which of the following findings indicates a need for further testing?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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