NUR 155 Med-Surg Test 3 - Answered with Rationales (Complete Solutions)

NUR 155 Test 3 - Answered with Rationales (Complete Solutions) A severely obese patient has undergone Roux-en-Y gastric bypass surgery. In planning postoperative care, the nurse anticipates that the patient A. may have ...

NUR 155 Test 3 - Answered with Rationales (Complete Solutions) A severely obese patient has undergone Roux-en-Y gastric bypass surgery. In planning postoperative care, the nurse anticipates that the patient A. may have severe diarrhea early in the postoperative period. B. will not be allowed to ambulate for 1 to 2 days postoperatively. C. will require nasogastric suction until the incision heals. D. may have only liquids orally, and in very limited amounts, during the postoperative period. Rationale: During the immediate postoperative period, water and sugar-free clear liquids are given (30 mL every 2 hours while the patient is awake). You are providing care to a patient with COPD who is receiving medical treatment for exacerbation. The patient has a history of diabetes, hypertension, and hyperlipidemia. The patient is experiencing extreme hyperglycemia. In addition, the patient has multiple areas of bruising on the arms and legs. Which medication ordered for this patient can cause hyperglycemia and bruising? A) Prednisone B) Atrovent C) Flagyl D) Levaquin Rationale: Prednisone is a corticosteroid and can cause hyperglycemia and bruising. (SATA) Which of the following statements are incorrect about discharge teaching that you would provide to a patient with COPD? 1. "It is best to eat three large meals a day that are relatively low in calories 2. "Avoid going outside during extremely hot or cold days." 3. "It is important to receive the Pneumovax vaccine annually." 4. "Smoking cessation can help improve your symptoms." A) 1,4 B) 1,3 C) 2,4 D) 1,2,3 E) All of these F) None Rationale: The answers are 1 and 4. The patient needs to eat high calorie and protein rich meals that are small but frequent. The pneumovax is definitely recommended for patients with COPD but is given every 5 years (not annually). Clients with chronic illnesses are more likely to get pneumonia when which of the following situations is present? A. Dehydration B. Group living C. Malnutrition D. Severe periodontal disease Rationale: Clients with chronic illnesses generally have poor immune systems. Often, residing in group living situations increases the chance of disease transmission. Pneumonia is a fairly prevalent disease and carries a heavy burden in all populations. A study carried out by the US Centers for Disease Control and Prevention (CDC) aimed at estimating its burden in North America found that CAP accounted for the eighth leading cause of mortality in the United States and the seventh leading cause of mortality in Canada after adjusting for various gender and age differences. - Option A: Pneumonia can also cause dehydration from fever and decreased thirst and appetite, which may require treatment with extra fluids intravenously. Potential benefits of fluids are replacing fluid lost because of fever or rapid breathing, treating dehydration, and reducing the viscosity of mucus. - Option C: Pneumonia is common in malnourished children and is frequently associated with fatal outcomes, especially in children younger than 24 months of age. Studies consistently reported a two- to threefold greater risk of mortality in cases with pneumonia associated with malnutrition. Therefore, pneumonia and malnutrition are two of the biggest killers in childhood diseases. - Option D: Various pathogenic bacteria have been found in patients with deep periodontal pockets. The association between periodontal disease and pneumonia may be due to colonization by pathogenic bacteria in the periodontal pocket, as inhalation of a pathogen is considered a risk factor for pneumonia Which of the following organisms most commonly causes community-acquired pneumonia in adults? A. Haemophilus influenzae B. Klebsiella pneumoniae C. Streptococcus pneumoniae D. Staphylococcus aureus Rationale: Pneumococcal or streptococcal pneumonia, caused by streptococcus pneumoniae, is the most common cause of community-acquired pneumonia. Streptococcus pneumoniae is the bacterium that has historically been the most common pathogen to cause CAP worldwide. In the era before antibiotics, S. pneumoniae was estimated to be the cause of 95% of all cases of pneumonia. Currently, however, S. pneumoniae accounts for up to 15% of pneumonia cases in the United States and 27% of cases worldwide today. -Option A: H. influenzae is the most common cause of infection in children. Haemophilus influenzae is a bacteria characterized as a small, facultatively anaerobic, pleomorphic, and capnophilic gram-negative coccobacillus of the family Pasteurellaceae. It is a common cause of a variety of invasive and non-invasive bacterial infections. -Option B: Klebsiella species is the most common gram-negative organism found in the hospital setting. Today, K. pneumoniae pneumonia is considered the most common cause of hospital-acquired pneumonia in the United States, and the organism accounts for 3% to 8% of all nosocomial bacterial infections. -Option D: Staphylococcus aureus is the most common cause of hospital-acquired pneumonia. Staphylococcus aureus is a major bacterial human pathogen that causes a wide variety of clinical manifestations. Infections are common both in community-acquired as well as hospital-acquired settings and treatment remains challenging to manage due to the emergence of multi-drug resistant strains such as MRSA (Methicillin-Resistant Staphylococcus aureus). An elderly client with pneumonia may appear with which of the following symptoms first? A. Altered mental status and dehydration B. Fever and chills C. Hemoptysis and dyspnea D. Pleuritic chest pain and cough Rationale: Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are common symptoms of pneumonia, but elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response. A small fraction of patients may have an altered mental status, abdominal pain, chest pain, and other systemic findings. - Option B: Historically, the chief complaints in case of pneumonia include systemic signs like fever with chills, malaise, loss of appetite, and myalgia. These findings are more common in viral pneumonia as compared to bacterial pneumonia. - Option C: Pulmonary findings include cough with or without sputum production. Bacterial pneumonia is associated with purulent or rarely blood-tinged sputum. Viral pneumonia is associated with watery or occasionally mucopurulent sputum production. - Option D: There may be an associated pleuritic chest pain with the concomitant involvement of the pleura. Dyspnea and a diffuse heaviness of the chest are also seen occasionally. The cough may be either non productive or productive with mucoid, purulent, or blood-tinged sputum. A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests? A. ABG analysis B. Chest x-ray C. Blood cultures D. Sputum culture and sensitivity Rationale: Sputum C & S is the best way to identify the organism causing the pneumonia. If good quality, sputum evaluation may reveal more than 25 WBC per low-power field and less than 10 squamous epithelial cells. Some bacterial causes present with specific biochemical evidence, such as Legionella, may present with hyponatremia and microhematuria. - Option A: ABG analysis will determine the extent of hypoxia present due to the pneumonia. An arterial blood gas may reveal hypoxia and respiratory acidosis. Pulse oximetry of less than 92% indicates severe hypoxia, and elevated CRP predicts a serious infection. - Option B: Chest x-ray will show the area of lung consolidation. Findings may vary from lobar to interstitial infiltrate, to occasionally cavitary lesions with air-fluid levels suggestive of a more severe disease process. - Option C: Blood cultures will help determine if the infection is systemic. These include a series of tests like blood culture, sputum culture and microscopy, routine blood counts, and lymphocyte count. Special tests such as urinary antigen testing, bronchial aspirate, or induced sputum may be used for certain pathogens. A client with pneumonia develops dyspnea with a respiratory rate of 32 breaths/minute and difficulty expelling his secretions. The nurse auscultates his lung fields and hears bronchial sounds in the left lower lobe. The nurse determines that the client requires which of the following treatments first? A. Antibiotics B. Bed rest C. Oxygen D. Nutritional intake Rationale: The client is having difficulty breathing and is probably becoming hypoxic. As an emergency measure, the nurse can provide oxygen without waiting for a physician's order. Anticipate the need for supplemental oxygen or intubation if the patient's condition deteriorates. These measures are needed to correct hypoxemia. Intubation is needed for deep suctioning efforts and provides a source for augmenting oxygenation. - Option A: Antibiotics may be warranted, but this isn't a nursing decision. Administer prescribed antimicrobial agents as ordered. To prevent relapse of pneumonia, the patient needs to complete the course of antibiotics as prescribed. - Option B: The client should be maintained on bedrest if he is dyspneic to minimize his oxygen demands, but providing additional will deal more immediately with his problem. Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake. Facilitates the healing process and enhances natural resistance. - Option D: The client will need nutritional support, but while dyspneic, he may be unable to spare the energy needed to eat and at the same time maintain adequate oxygenation. Maintain adequate nutrition to offset hypermetabolic state secondary to infection. Ask the dietary department to provide a high-calorie, high-protein diet consisting of soft, easy-to-eat foods. A client has been treated with antibiotic therapy for right lower-lobe pneumonia for 10 days and will be discharged today. Which of the following physical findings would lead the nurse to believe it is appropriate to discharge this client? A. Continued dyspnea B. Fever of 102*F C. Respiratory rate of 32 breaths/minute. D. Vesicular breath sounds in the right base. Rationale: If the client still has pneumonia, the breath sounds in the right base will be bronchial, not the normal vesicular breath sounds. If the client still has dyspnea, fever, and increased respiratory rate, he should be examined by the physician before discharge because he may have another source of infection or still have pneumonia. - Option A: Assess the rate, rhythm, and depth of respiration, chest movement, and use of accessory muscles. Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of the discomfort of moving chest wall and/or fluid in the lung due to a compensatory response to airway obstruction. Altered breathing pattern may occur together with the use of accessory muscles to increase chest excursion to facilitate effective breathing. - Option B: Investigate sudden change in condition, such as increasing chest pain, extra heart sounds, altered sensorium, recurring fever, changes in sputum characteristics. Delayed recovery or increase in severity of symptoms suggests resistance to antibiotics or secondary infection. - Option C: Assess and record respiratory rate and depth at least every 4 hours. The average rate of respiration for adults is 10 to 20 breaths per minute. It is important to take action when there is an alteration in the pattern of breathing to detect early signs of respiratory compromise. The right forearm of a client who had a purified protein derivative (PPD) test for tuberculosis is reddened and raised about 3mm where the test was given. This PPD would be read as having which of the following results? A. Indeterminate B. Needs to be redone C. Negative D. Positive Rationale: This test would be classed as negative. A 5 mm raised area would be a positive result if a client was HIV+ or had recent close contact with someone diagnosed with TB. If the patient is at a high risk of developing an active infection, a repeat test is recommended after an initial negative test to rule out the possibility of missing a case. However, a decision is made based on the risk factors. - Option A: Indeterminate isn't a term used to describe results of a PPD test. It is a time-sensitive test. Tests that are read late are not accurate as they tend to underestimate the size of the skin reaction. Therefore, the reliability of the test is compromised, and the results are doubtful. - Option B: To avoid this, repeat testing is recommended if the reaction is not read on time. The second test can be administered as soon as possible. However, if repeated, the test should preferably be performed within 7 days of the initial test to avoid boosting effect. - Option D: If the PPD is reddened and raised 10mm or more, it's considered positive according to the CDC. If the infection risk is very high, the PPD test need not be repeated. The positive PPD test is usually followed by TB symptom assessment, physical exam, and chest radiograph. A client with primary TB infection can expect to develop which of the following conditions? A. Active TB within 2 weeks B. Active TB within 1 month C. A fever that requires hospitalization. D. A positive skin test. Rationale: A primary TB infection occurs when the bacillus has successfully invaded the entire body after entering through the lungs. At this point, the bacilli are walled off and skin tests read positive. However, all but infants and immunosuppressed people will remain asymptomatic. The general population has a 10% risk of developing active TB over their lifetime, in many cases because of a break in the body's immune defenses. The active stage shows the classic symptoms of TB: fever, hemoptysis, and night sweats. - Option A: The tubercle bacilli will proliferate until an effective cell-mediated immune response develops. This usually takes about 2 to 10 weeks following initial infection in more than 90% of infected individuals. In the lungs, failure to mount an effective cell-mediated immune response and tissue repair could lead to extensive damage. - Option B: About 5 % of patients develop primary active tuberculosis secondary to inadequate T-cell immunity. About 5-10% of patients with latent infections progress to active disease in their lifetime, most commonly in the initial two years. If untreated, half of those with the active disease die. - Option C: In pulmonary tuberculosis, the most commonly reported symptom is a chronic cough. Cough most of the time is productive, sometimes mixed with blood. Constitutional symptoms like fever, weight loss, lymphadenopathy, and night sweats are commonly reported. A client was infected with TB 10 years ago but never developed the disease. He's now being treated for cancer. The client begins to develop signs of TB. This is known as which of the following types of infection? A. Active infection B. Primary infection C. Superinfection D. Tertiary infection Rationale: Some people carry dormant TB infections that may develop into active disease. In addition, primary sites of infection containing TB bacilli may remain inactive for years and then activate when the client's resistance is lowered, as when a client is being treated for cancer. There's no such thing as tertiary infection, and superinfection doesn't apply in this case. - Option B: Primary (initial) infection is usually indicated by tuberculin skin test (TST) or interferon-gamma release assay (IGRA) conversion, which reflects a delayed type hypersensitivity reaction to protein products of M. tuberculosis. Primary infection remains undiagnosed in the majority of cases, as symptoms are mild, non-specific, and usually self-resolving. - Option C: Superinfection is the process by which a cell that has previously been infected by one virus gets co-infected with a different strain of the virus, or another virus, at a later point in time. Viral superinfections may be resistant to the antiviral drug or drugs that were being used to treat the original infection. - Option D: There is no tertiary infection in tuberculosis. A re-infection event probably triggers very similar responses to those observed with primary (first-time) infection and the risk of subsequent disease progression seems to be substantially reduced. However, re-infection is likely to occur multiple times during the lifetime of an individual living in a TB endemic area, which explains its large contribution to the disease burden observed. A client has active TB. Which of the following symptoms will he exhibit? A. Chest and lower back pain. B. Chills, fever, night sweats, and hemoptysis. C. Fever of more than 104*F and nausea. D. Headache and photophobia. Rational: Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Constitutional symptoms like fever, weight loss, lymphadenopathy, and night sweats are commonly reported. Extra pulmonary tuberculosis can affect any organ and can have a varied presentation. In pulmonary tuberculosis, the most commonly reported symptom is a chronic cough. Cough most of the time is productive, sometimes mixed with blood. • Option A: Chest pain may be present from coughing, but isn't usual. Secondary tuberculosis differs in clinical presentation from the primary progressive disease. In secondary disease, the tissue reaction and hypersensitivity is more severe, and patients usually form cavities in the upper portion of the lungs. • Option C: Clients with TB typically have low-grade fevers, not higher than 102*F. A chronic cough, hemoptysis, weight loss, low-grade fever, and night sweats are some of the most common physical findings in pulmonary tuberculosis. • Option D: Nausea, headache, and photophobia aren't usual TB symptoms. Pulmonary or systemic dissemination of the tubercles may be seen in active disease, and this may manifest as miliary tuberculosis characterized by millet-shaped lesions on chest x-ray. Disseminated tuberculosis may also be seen in the spine, the central nervous system, or the bowel. Which of the following diagnostic tests is definitive for TB? A. Chest x-ray B. Mantoux test C. Sputum culture D. Tuberculin test Rational: The sputum culture for Mycobacterium tuberculosis is the only method of confirming the diagnosis. Mycobacterial culture is the gold standard for diagnosis. Mycobacterial culture should be performed on both the solid and liquid medium. Liquid media culture can detect very low bacterial load and is considered a gold standard. Culture essential for drug susceptibility testing. • Option A: Lesions in the lung may not be big enough to be seen on x-ray. A chest x-ray is indicated to rule out or rule in the presence of active disease in all screening test positive cases. In pulmonary tuberculosis, initial testing includes a chest X-Ray, sputum evaluation. • Option B: Skin tests may be falsely positive or falsely negative. The Mantoux reaction following injection of a dose of PPD (purified protein derivative) is the traditional screening test for exposure to Tuberculosis. The result is interpreted taking into consideration the patient's overall risk of exposure. Patients are classified into 3 groups based on the risk of exposure with three corresponding cut-off points. • Option D: Note that a Mantoux test indicates exposure or latent tuberculosis. However, this test lacks specificity, and patients would require subsequent visits for interpreting the results as well as chest x-ray for confirmation. Although relatively sensitive, the Mantoux reaction is not very specific and may give false-positive reactions in individuals who have been exposed to the BCG-vaccine. A client with a positive Mantoux test result will be sent for a chest x-ray. For which of the following reasons is this done? A. To confirm the diagnosis. B. To determine if a repeat skin test is needed. C. To determine the extent of the lesions. D. To determine if this is a primary or secondary infection. Rational: If the lesions are large enough, the chest x-ray will show their presence in the lungs. A positive Mantoux test indicates exposure to tuberculosis or latent tuberculosis. However, this test lacks specificity, and patients require subsequent visits to interpret the result and a chest x-ray for confirmation of the disease. • Option A: Sputum culture confirms the diagnosis. Mycobacterial culture is the gold standard for diagnosis. Mycobacterial culture should be performed on both the solid and liquid medium. Liquid media culture can detect very low bacterial load and is considered a gold standard. Culture essential for drug susceptibility testing. • Option B: There can be false-positive and false-negative skin test results. Although the test is considered relatively sensitive, false-positive results are seen with BCG vaccination. The Mantoux test should never be regarded as a confirmatory test. • Option D: A chest x-ray can't determine if this is a primary or secondary infection. Apart from these, Tuberculin skin testing and/or interferon-gamma release assay should be performed depending on the situation. These tests should not be wholly relied upon in the diagnosis of active tuberculosis, but assist in diagnosis. A client with a positive skin test for TB isn't showing signs of active disease. To help prevent the development of active TB, the client should be treated with isoniazid, 300 mg daily, for how long? A. 10 to 14 days B. 2 to 4 weeks C. 3 to 6 months D. 9 to 12 months Rational: Because of the increased incidence of resistant strains of TB, the disease must be treated for up to 24 months in some cases, but treatment typically lasts for 9-12 months. Isoniazid is the most common medication used for the treatment of TB, but other antibiotics are added to the regimen to obtain the best results. • Option A: Drug of choice is isoniazid. It is usually given with vitamin B6, pyridoxine (to prevent nerve damage). Isoniazid is recommended for Mantoux or quantiferon positive individuals and should be continued for 6 or 9 months. • Option B: Treatment of confirmed TB requires a combination of drugs. Combination therapy is always indicated, and monotherapy should never be used for tuberculosis. The combination of first-line and second-line medications are used at high doses to treat this condition. • Option C: Isoniazid and Rifampicin follow a 4-drug regimen (usually including Isoniazid, Rifampicin, Ethambutol, and Pyrazinamide) for 2 months or six months. Vitamin B6 is always given with Isoniazid to prevent neural damage (neuropathies). A client with a productive cough, chills, and night sweats is suspected of having active TB. The physician should take which of the following actions? A. Admit him to the hospital in respiratory isolation. B. Prescribe isoniazid and tell him to go home and rest. C. Give a tuberculin test and tell him to come back in 48 hours and have it read. D. Give a prescription for isoniazid, 300 mg daily for 2 weeks, and send him home. Rational: The client is showing s/s of active TB and because of a productive cough is highly contagious. He should be admitted to the hospital, placed in respiratory isolation, and three sputum cultures should be obtained to confirm the diagnosis. After 7 to 10 days, three more consecutive sputum cultures will be obtained. If they're negative, he would be considered non-contagious and may be sent home, although he'll continue to take the antitubercular drugs for 9 to 12 months. • Option B: He would most likely be given isoniazid and two or three other antitubercular antibiotics until the diagnosis is confirmed, then isolation and treatment would continue if the cultures were positive for TB. It is usually given with vitamin B6, pyridoxine (to prevent nerve damage). Isoniazid is recommended for Mantoux or quantiferon positive individuals and should be continued for 6 or 9 months. • Option C: Note that a Mantoux test indicates exposure or latent tuberculosis. However, this test lacks specificity, and patients would require subsequent visits for interpreting the results as well as chest x-ray for confirmation. Although relatively sensitive, the Mantoux reaction is not very specific and may give false positive reactions in individuals who have been exposed to the BCG-vaccine. • Option D: Treatment of confirmed TB requires a combination of drugs. Combination therapy is always indicated, and monotherapy should never be used for tuberculosis. Isoniazid and Rifampicin follow a 4-drug regimen (usually including Isoniazid, Rifampicin, Ethambutol, and Pyrazinamide) for 2 months or six months. Vitamin B6 is always given with Isoniazid to prevent neural damage (neuropathies). A high level of oxygen exerts which of the following effects on the lung? A. Improves oxygen uptake. B. Increases carbon dioxide levels. C. Stabilizes carbon dioxide levels. D. Reduces amount of functional alveolar surface area. Rational: Oxygen toxicity causes direct pulmonary trauma, reducing the amount of alveolar surface area available for gaseous exchange, which results in increased carbon dioxide levels and decreased oxygen uptake. Continued exposure to high concentrations of oxygen results in heightened free radical production. This may damage the pulmonary epithelium, inactivate the surfactant, form intra-alveolar edema, interstitial thickening, fibrosis, and ultimately lead to pulmonary atelectasis. • Option A: Oxygen-derived free radicals have been proposed as being the probable etiological cause in the development of oxygen toxicity. Free radicals are generated due