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 D

Explanation

A. This response may come across as judgmental or directive, which can be perceived as dismissive of the client's struggle. It does not acknowledge the complexity of the disorder or the client's feelings of helplessness, potentially hindering open communication and trust.
B. While this question encourages exploration of the underlying reasons for the behavior, it might feel probing or intrusive to the client. It could be interpreted as focusing solely on the behavior itself rather than acknowledging the client's recognition of its abnormality or their feelings of helplessness.
C. This response acknowledges and validates the client's awareness of the problem, which can be empowering. It reinforces the client's self-awareness and readiness to address their behavior, promoting a therapeutic alliance based on mutual understanding and respect.
D. This response demonstrates empathy and understanding of the client's feelings. It acknowledges the emotional struggle the client is experiencing and opens the door for further exploration of their feelings and thoughts. It encourages the client to express their emotions and concerns, which is essential in building a supportive therapeutic relationship.

A. A client who has end-stage kidney disease who will undergo dialysis B. A client who has gastroenteritis and is receiving oral fluids C. A client who has heart failure and is receiving diuretic therapy D. A client who has NPO status since midnight for an endoscopy

Correct Answer is B

Explanation

A. Clients with end-stage kidney disease often have impaired kidney function, leading to decreased urine output and retention of fluid and waste products. Dialysis is intended to remove excess fluid and waste from the body.
B. Gastroenteritis involves inflammation of the gastrointestinal tract, leading to symptoms such as diarrhea and vomiting. These symptoms result in significant fluid loss.
C. Heart failure can lead to fluid retention and edema due to the heart's inability to pump effectively. Diuretic therapy is commonly prescribed to manage fluid overload by increasing urine output. However, excessive diuresis or inadequate intake of fluids can lead to fluid volume deficit, particularly if the client does not compensate with adequate oral intake.

D. This client has been NPO only since midnight (about 9–14 hours, depending on procedure time). While intake is restricted, this short period is not usually enough to cause a significant fluid volume deficit, unless prolonged.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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