Brunner & Suddarth's textbook of medical-surgical Nursing (13th) ch23
1. After diagnosing a client with pulmonary tuberculosis, the physician tells
family members that they must receive isoniazid (INH [Laniazid]) as
prophylaxis against tuberculosis. The client's daughter asks the nurse how
long the drug must be taken. What is the usual duration of prophylactic
isoniazid therapy?
3 to 5 days
1 to 3 weeks
6 to 12 months
2 to 4 months: 6-12 months
Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage
of 300 mg. Taking the drug for less than 6 months may not provide adequate
protection against tuberculosis.
2. A nurse is caring for a client with chest trauma. Which nursing diagnosis
takes the highest priority?
Ineffective tissue perfusion (cardiopulmonary)
Impaired gas exchange
Anxiety
Decreased cardiac output: Impaired gas exchange
For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority
because adequate gas exchange is essential for survival. Although the other
nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue
perfusion (cardiopulmonary) — are possible for this client, they are lower priorities
than Impaired gas exchange.
3. A nurse is assessing a client who comes to the clinic for care. Which
findings in this client suggest bacterial pneumonia?
Dyspnea and wheezing
Nonproductive cough and normal temperature
Hemoptysis and dysuria
Sore throat and abdominal pain: Dyspnea and wheezing
In a client with bacterial pneumonia, retained secretions cause dyspnea, and
respiratory tract inflammation causes wheezing. Bacterial pneumonia also
produces a productive cough and fever, rather than a nonproductive cough and
normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia.
1/8
, Brunner & Suddarth's textbook of medical-surgical Nursing (13th) ch23
Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can
reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't
associated with pneumonia.
4. When caring for a client with acute respiratory failure, the nurse should
expect to focus on resolving which set of problems?
Hypotension, hyperoxemia, and hypercapnia
Hyperoxemia, hypocapnia, and hyperventilation
Hypercapnia, hypoventilation, and hypoxemia
Hyperventilation, hypertension, and hypocapnia: hypercapnia, hypoventilation,
and hypoxemia
The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia,
hypoventilation, and hypoxemia. The nurse should focus on resolving these
problems.
5. 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 infec-
tion. presence of a wheal at the injection site in 2 days indicates active
tuberculosis.: 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.
6. 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
2/8
1. After diagnosing a client with pulmonary tuberculosis, the physician tells
family members that they must receive isoniazid (INH [Laniazid]) as
prophylaxis against tuberculosis. The client's daughter asks the nurse how
long the drug must be taken. What is the usual duration of prophylactic
isoniazid therapy?
3 to 5 days
1 to 3 weeks
6 to 12 months
2 to 4 months: 6-12 months
Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage
of 300 mg. Taking the drug for less than 6 months may not provide adequate
protection against tuberculosis.
2. A nurse is caring for a client with chest trauma. Which nursing diagnosis
takes the highest priority?
Ineffective tissue perfusion (cardiopulmonary)
Impaired gas exchange
Anxiety
Decreased cardiac output: Impaired gas exchange
For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority
because adequate gas exchange is essential for survival. Although the other
nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue
perfusion (cardiopulmonary) — are possible for this client, they are lower priorities
than Impaired gas exchange.
3. A nurse is assessing a client who comes to the clinic for care. Which
findings in this client suggest bacterial pneumonia?
Dyspnea and wheezing
Nonproductive cough and normal temperature
Hemoptysis and dysuria
Sore throat and abdominal pain: Dyspnea and wheezing
In a client with bacterial pneumonia, retained secretions cause dyspnea, and
respiratory tract inflammation causes wheezing. Bacterial pneumonia also
produces a productive cough and fever, rather than a nonproductive cough and
normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia.
1/8
, Brunner & Suddarth's textbook of medical-surgical Nursing (13th) ch23
Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can
reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't
associated with pneumonia.
4. When caring for a client with acute respiratory failure, the nurse should
expect to focus on resolving which set of problems?
Hypotension, hyperoxemia, and hypercapnia
Hyperoxemia, hypocapnia, and hyperventilation
Hypercapnia, hypoventilation, and hypoxemia
Hyperventilation, hypertension, and hypocapnia: hypercapnia, hypoventilation,
and hypoxemia
The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia,
hypoventilation, and hypoxemia. The nurse should focus on resolving these
problems.
5. 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 infec-
tion. presence of a wheal at the injection site in 2 days indicates active
tuberculosis.: 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.
6. 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
2/8
