A 67-yr-old male patient had a right total knee replacement 2
days ago. Upon auscultation of the patient's posterior chest, the
nurse detects discontinuous, high-pitched breath sounds just
before the end of inspiration in the lower portion of both lungs.
Which statement most appropriately reflects how the nurse
should document the breath sounds?
A. "Bibasilar wheezes present on inspiration."
B. "Diminished breath sounds in the bases of both lungs."
C. "Fine crackles posterior right and left lower lung fields."
D. "Expiratory wheezing scattered throughout the lung fields."
Correct Answers C. "Fine crackles posterior right and left lower
lung fields."
A frail 82-yr-old female patient develops sudden shortness of
breath while sitting in a chair. What location on the chest should
the nurse begin auscultation of the lung fields?
A. Bases of the posterior chest area
B. Apices of the posterior lung fields
C. Anterior chest area above the breasts
D. Midaxillary on the left side of the chest Correct Answers A.
Bases of the posterior chest area
,A home health nurse is teaching a client who has active TB. The
provider has prescribed the following medication regimen:
isoniazid 250 mg PO daily
rifampin 500 mg PO daily
pyrazinamide 750 mg PO daily
ethambutal 1 mg PO daily
Which of the following client statements indicate understanding
of the teaching? (Select all that apply)
A. I can substitute one medication for another if I run out
because they all fight infection.
B. I will wash my hands each time I cough.
C. I will wear a mask when I am in a public area.
D. I am glad I don't have to have any more sputum specimens.
E. I don't need to worry where I go once I start taking my
medications. Correct Answers B. I will wash my hands each
time I cough.
C. I will wear a mask when I am in a public area.
A nurse in a clinic is caring for a client whose partner states the
client woke up this morning, did not recognize him, and did not
know where she was. The client reports chills and chest pain that
, is worse upon inspiration. Which of the following actions is the
nursing priority?
A. Obtain baseline vital signs and oxygen saturation
B. Obtain a sputum culture
C. Obtain a complete history from the client
D. Provide a pneumococcal vaccine Correct Answers A.
Obtain baseline vital signs and oxygen saturation
A nurse is caring for a client who has a new diagnosis of TB and
has been placed on a multimedication regimen. Which of the
following instructions should the nurse give the client related to
ethambutol?
A. Your urine can turn dark orange.
B. Watch for a change in the sclera of your eyes.
C. Watch for any changes in vision.
D. Take vitamin B6 daily. Correct Answers C. Watch for any
changes in vision.
A nurse is caring for a client who is 1 hour post op following a
thoracentesis. Which of the following is the priority assessment
finding?
A. 99.1 temp