A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client?

Bacille Calmette-Guérin (bCG) vaccine

Chest x-ray

Sputum culture for acid fast bacillus (AFB)

Tuberculin skin test

Answer and Explanation

The Correct Answer is D

A.   The BCG vaccine is a vaccine used to prevent tuberculosis (TB) disease. However, its effectiveness varies widely and is primarily used in countries with a high prevalence of TB. Therefore, administering the BCG vaccine is not typically part of the evaluation process for TB exposure in a client.
B.   A chest x-ray is commonly used to evaluate for active pulmonary TB disease. It can identify characteristic findings such as infiltrates, cavitations, or nodular lesions in the lungs that suggest TB infection. A chest x- ray is often performed as part of the initial evaluation for TB after exposure or to assess for active disease.
C.   Sputum culture for AFB is a definitive diagnostic test for tuberculosis. It involves collecting sputum samples and culturing them in a laboratory to detect the presence of Mycobacterium tuberculosis, the bacterium that causes TB.
D.   The tuberculin skin test (TST), also known as the Mantoux test, involves injecting a small amount of purified protein derivative (PPD) into the skin of the forearm. After 48-72 hours, a healthcare provider assesses the size of the induration (swelling) at the injection site. A positive TST indicates exposure to TB but does not differentiate between latent TB infection (LTBI) and active TB disease.

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Correct Answer is C

Explanation

A. Glucagon is administered to increase blood glucose levels in hypoglycemic states. However, the client's glucose level is within the normal range (72 mg/dL), so administering glucagon is not appropriate.

B. Chvostek's sign is assessed to detect hypocalcemia, not hypokalemia. It involves tapping the facial nerve anterior to the earlobe and observing for facial muscle contraction. This action is not relevant to the potassium level and is not indicated based on the laboratory findings provided.
C. The client's potassium level of 3.0 mEq/L is below the normal range, indicating hypokalemia. Potassium replacement is essential to prevent complications such as cardiac arrhythmias. The nurse should follow the facility's protocol for administering potassium replacement, which may include adjusting the TPN solution or administering intravenous potassium supplements.
D. Discontinuing the TPN infusion is not warranted based solely on the potassium level. The TPN infusion provides essential nutrition and should not be stopped without addressing the electrolyte imbalance separately.

A. Decreased hematocrit B. Increased urine ketones C. Increased urine specific gravity D. Decreased BUN

Correct Answer is C

Explanation

A. Hematocrit measures the percentage of red blood cells in the blood. In fluid volume deficit, there is hemoconcentration due to decreased fluid volume, resulting in an increase in hematocrit rather than a decrease. Therefore, a decreased hematocrit would not be an expected finding in fluid volume deficit.
B. Urine ketones are typically elevated in conditions where there is increased fat metabolism, such as in diabetic ketoacidosis or starvation. They are not directly related to fluid volume deficit and would not be an expected finding.
C. Urine specific gravity measures the concentration of solutes in the urine, indicating the kidney's ability to concentrate or dilute urine. In fluid volume deficit, the body conserves water, leading to increased urine concentration and higher urine specific gravity. Therefore, increased urine specific gravity is an expected finding in fluid volume deficit.
D. BUN is a measure of kidney function and protein metabolism. In fluid volume deficit, there is hemoconcentration due to decreased fluid volume, which can lead to an increase in BUN rather than a decrease. A decreased BUN would not typically be an expected finding in fluid volume deficit.

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A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L. sodium 138 mEq/L and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is collecting data for a client who has fluid volume deficit. Which of the following is an expected finding?

Correct Answer is C

Explanation

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