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Questions 164

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Extract:


Question 1 of 5

The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply.

Correct Answer: A,B,C,E

Rationale: Rinsing the mouth, avoiding contamination, deep coughing, and sitting upright ensure a quality specimen. Morning collection is preferred for higher yield.

Question 2 of 5

The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

Correct Answer: A

Rationale: Extreme fatigue. Extreme fatigue and weakness are common, early signs of digitalis toxicity, which would be confirmed by a high blood serum level of digitalis.

Question 3 of 5

The nurse is caring for a client diagnosed with active pulmonary tuberculosis. Which elements of transmission-based precautions are required for the nurse when providing routine care? Select all that apply.

Correct Answer: C,D

Rationale: Active pulmonary tuberculosis requires airborne precautions, including hand hygiene and an N95 respirator. A surgical mask is insufficient.

Question 4 of 5

An adult is admitted with a possible detached retina. Which findings would the nurse expect during the admission assessment?

Correct Answer: B

Rationale: Detached retina causes a visual field defect, like a blank area or curtain, due to retinal separation, unlike pain, halos (glaucoma), or tunnel vision.

Question 5 of 5

The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant notification of the supervising registered nurse?

Correct Answer: A

Rationale: Benztropine can increase intraocular pressure, worsening glaucoma, and requires immediate follow-up.

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