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. Indwelling urinary catheters are associated with an increased risk of urinary tract infections (UTIs) and other complications, including skin irritation and breakdown around the catheter site. Routine use of indwelling catheters is not recommended for managing routine urinary incontinence due to these risks.

B. Using hot water or harsh cleansers can strip the skin of its natural oils and lead to further irritation and breakdown. Instead, gentle cleansing with mild soap and warm water is recommended after each episode of incontinence to remove urine and prevent skin irritation. Patting the skin dry rather than rubbing can also help prevent damage to the skin barrier.
C. Regular skin assessment is crucial in clients with urinary incontinence to identify early signs of skin breakdown. Checking the skin every 8 hours may not be frequent enough, particularly if the client is incontinent frequently. More frequent assessment, ideally after each episode of incontinence or at least every 2-4 hours, is recommended to promptly identify and address any skin issues.
D. Applying a moisture barrier ointment or cream to the perineal area and any areas prone to moisture can help protect the skin from urine and fecal exposure. These products create a barrier that prevents direct contact of urine with the skin, reducing the risk of irritation and breakdown. Regular application, especially after cleansing and as needed throughout the day, can help maintain skin integrity.

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 D

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. NPO (nothing by mouth) status for procedures such as endoscopy prevents oral intake of fluids and food. Depending on the duration of NPO status and the client's baseline fluid needs, prolonged restriction can lead to dehydration and 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 caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown?

Correct Answer is D

Explanation

A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

Correct Answer is D

Explanation

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