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Questions 164

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Question 1 of 5

An elderly client has a 17-mm induration after a tuberculin skin test. Based on this result, which statement is most accurate?

Correct Answer: B

Rationale: A 17-mm induration in an elderly client indicates TB infection, as the threshold is ≥10 mm for high-risk groups. It doesn't confirm active disease, which requires further testing (e.g., chest X-ray). False positives are possible but not assumed based on age alone. Isolation isn't required without active disease.

Question 2 of 5

The nurse is caring for a man who had a transsphenoidal hypophysectomy earlier today. He says he has to spit a lot. What nursing action is essential?

Correct Answer: B

Rationale: Excessive spitting may indicate cerebrospinal fluid (CSF) leak, which contains glucose; testing secretions confirms this serious complication.

Question 3 of 5

During the discharge teaching of a client with Buerger's disease, the nurse should teach the client:

Correct Answer: A

Rationale: Exercises to improve vascular return, such as ankle pumps, help manage Buerger's disease by promoting circulation in the extremities.

Question 4 of 5

The health care provider has just prescribed tetracycline for an adolescent with acne vulgaris. The client takes oral contraceptive pills. The nurse should reinforce teaching about which topics? Select all that apply.

Correct Answer: A,D,E

Rationale: Tetracycline binds to calcium in dairy, reducing absorption. It can reduce oral contraceptive efficacy, requiring backup methods. Photosensitivity necessitates sunblock. Taking with food or at bedtime is acceptable but not critical teaching.

Question 5 of 5

When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority?

Correct Answer: C

Rationale: Ask for a log of urinary output. Monitoring urine output is the best indicator of renal function in pyelonephritis.

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