The nurse is caring for a 48-year-old-client admitted with complaints of fatigue and hemoptysis, but no other significant medical history. Social history includes smoking 1 pack/day x 20 years and occasional alcohol use. He denies taking any medication. The Mantoux test placed 72 hours earlier reveals an indurated area of 4 cm. Which action will the nurse plan to include in the care for this client?
Prepare to administer intravenous (IV) antibiotics
Prepare client for computerized.tomography (CT scan)
Prepare to start oxygen therapy
Place client in airborne isolation
The Correct Answer is D
The client's complaint of hemoptysis (coughing up blood) and a positive Mantoux test (4 cm induration) suggest the possibility of tuberculosis (TB) infection. TB is an airborne infectious disease, and placing the client in airborne isolation is necessary to prevent the spread of the infection to others.
Antibiotics may be used to treat tuberculosis, but the initial step would be to isolate the client and confirm the diagnosis before starting specific treatment.
A CT scan may be ordered to further evaluate the client's condition, but it is not the immediate action required in this case. Isolation and confirmation of the diagnosis take priority. While the client may require oxygen therapy based on their respiratory symptoms, it is not the primary action to take at this stage. Isolation and further evaluation are necessary before initiating specific treatments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Kawasaki disease is an inflammatory condition that primarily affects children, causing symptoms such as fever, rash, conjunctivitis, swollen lymph nodes, and changes in the hands and feet, including skin peeling. It is important to create a calm and quiet environment for the child to minimize stimulation and discomfort.
Placing the child in a quiet environment helps reduce irritability and allows the child to rest. It also helps prevent further stress and agitation, which can exacerbate the symptoms of
Kawasaki disease. Providing a quiet space can promote comfort and improve the child's overall well-being.
Applying lotion to the hands and feet may be beneficial for soothing any dry or peeling skin, but it is not the priority intervention. Creating a quiet environment to address the child's irritability and discomfort takes precedence.
Encouraging the parents to rest when possible and making a list of foods that the child likes are important aspects of care, but they are not the immediate interventions to address the child's current symptoms of irritability, refusal to eat, and skin peeling. These interventions can be addressed after providing a quiet environment and ensuring the child's comfort.
Correct Answer is D
Explanation
The development of nausea and increased upper abdominal bowel sounds after 24 hours of NG decompression in a patient with gastric outlet obstruction raises concerns for possible complications or changes in the patient's condition. Assessing the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, can provide important information about their circulatory status and overall stability.
While checking the patency of the NG tube is important, it is not the best immediate action in this situation. The nurse should first assess the patient's vital signs to ensure their stability before proceeding with further interventions.
Placing the patient in a recumbent position (lying down) or encouraging deep breathing and conscious relaxation may not address the underlying issue and could potentially exacerbate the symptoms. It is essential to assess the patient's vital signs and circulatory status to determine the appropriate course of action.
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