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 A

Explanation

A. Positioning the client's arm above heart level can result in a falsely low blood pressure reading. This is because gravity assists in the flow of blood downward, artificially reducing the pressure measured in the arteries. For accurate blood pressure measurement, the client's arm should be positioned at heart level or slightly below heart level.
B. If the blood pressure cuff is wrapped too loosely around the client's arm, it can lead to inaccurate readings. A loose cuff may allow leakage of air during inflation or may not provide sufficient compression to accurately detect the arterial pressure pulses.
C. Deflating the cuff too slowly can cause a falsely high diastolic pressure reading. When the cuff is deflated slowly, the pressure in the cuff remains close to the systolic pressure for a longer duration, leading to incorrect readings, especially in diastolic pressure.
Blood pressure can temporarily increase after meals due to digestion, particularly in clients with hypertension. Measuring blood pressure immediately after a meal may result in a higher reading that does not reflect the client's baseline blood pressure. However, this would typically lead to a higher reading rather than a lower one.

A. "I will be certain to take enteric-coated medications." B. "I will empty my pouch when it becomes one third full." C. "I will change my entire pouch system at least weekly." D. "I will use caution when eating high fiber foods."

Correct Answer is A

Explanation

A. Enteric-coated medications are designed to dissolve in the small intestine rather than the stomach. This is important for ileostomy patients because medications that dissolve in the stomach may be poorly absorbed or can cause irritation to the stoma or the small intestine.
B. It's recommended to empty the ostomy pouch when it's about one-third to half full to prevent leakage or discomfort.
C. How often the pouch system needs to be changed can vary depending on individual factors such as skin sensitivity, output consistency, and the type of pouch system used. Generally, changing the pouch system every 3-7 days is recommended.
D. High fiber foods can increase stool output and gas production, which can be challenging for individuals with an ileostomy. However, fiber is important for overall digestive health, so moderation rather than avoidance is typically recommended.

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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 A

Explanation

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Correct Answer is A

Explanation

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