Brunner & Suddarth's Textbook of Medical-Surgical Nursing Exam 3 & 4 || All Questions & Answers (100% Accurate)

Brunner & Suddarth's Textbook of Medical-Surgical Nursing Exam 3 & 4 || All Questions & Answers (100% Accurate) Brunner & Suddarth's Textbook of Medical-Surgical Nursing Exam 3 & 4 || All Questions & Answers (100% Accurate) A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: area of redness is measured in 3 days and determines whether tuberculosis is present. test stimulates a reddened response in some clients and requires a second test in 3 months. skin test doesn't differentiate between active and dormant tuberculosis infection. presence of a wheal at the injection site in 2 days indicates active tuberculosis. - ANSWER - skin test doesn't differentiate between active and dormant tuberculosis infection. The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis. A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? Pulmonary embolism Myocardial infarction (MI) Pneumothorax Heart failure - ANSWER - Pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure. Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? Apply a compression dressing to the area Record the observation Report the finding to the physician immediately Measure the patient's pulse oximetry - ANSWER - Record the observation Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure. Subcutaneous emphysema is a typical postoperative finding in the patient after chest surgery. Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted. Subcutaneous emphysema results from air entering the tissue planes. Which type of pneumonia has the highest incidence in AIDS patients and patients receiving immunosuppressive therapy for cancer? Fungal TB Streptococcal Pneumocystis - ANSWER - Pneumocystis Pneumocystis pneumonia incidence is greatest in patient with AIDS and patients receiving immunosuppressive therapy for cancer. Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?