The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding?

Correct Answer: C

Rationale: Cor pulmonale (right heart failure due to lung disease) commonly causes peripheral edema due to fluid retention.

Correct Answer: D

Rationale: The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs.

Correct Answer: A

Rationale: The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube.

Correct Answer: B

Rationale: A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles.

Correct Answer: D

Rationale: Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (e.g., chest x-ray) will need to be used in determining whether the patient has a TB infection.