A nurse on a medical-surgical unit is caring for a newly admitted client with a diagnosis of R/O tuberculosis.

Which of the following findings should the nurse report to the provider?

Nurses' Notes

Day 1:

0900:

Client admitted from emergency department with hemoptysis, dull chest pain, increasing fatigue, anorexia, nausea, chest tightness, and 3.2 kg (7 Ib) weight loss in 2 weeks. Heart rate regular, lung sounds with crackles in bilateral upper lobes. No edema. Airborne precautions initiated upon admission.

Day 2:

Client reports shortness of breath, nausea, and fatigue. Crackles auscultated bilaterally throughout lung fields. Productive cough, with thick, blood-streaked sputum. Bowel sounds active, no edema.

Yellow sclera

Increasing AST level

Weight loss

Mantoux test result

Answer and Explanation

The Correct Answer is A

This is because tuberculosis can affect the liver and cause hepatotoxicity, especially if the client is taking anti-tuberculosis medications. The nurse should monitor the client's liver function tests, such as AST and ALT levels, and observe for signs of liver damage, such as yellow sclera, dark urine, clay-colored stools, and abdominal pain.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

This is because aspirin can cause salicylate toxicity, which can manifest as tinnitus, hearing loss, vertigo, headache, confusion, and hyperventilation. The nurse should monitor the client's serum salicylate level and advise the client to report any signs of toxicity to the provider.

A. 800 mL B. 480 mL C. 950 mL D. 300 mL

Correct Answer is B

Explanation

This is because the recommended tidal volume for mechanical ventilation is 6 to 8 mL/kg of ideal body weight. Therefore, for a client who has an ideal weight of 60 kg, the tidal volume should be between 360 and 480 mL. A tidal volume that is too high or too low can cause lung injury or hypoventilation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following?

Correct Answer is B

Explanation

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

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