A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client?

Bacille Calmette-Guérin (bCG) vaccine

Chest x-ray

Sputum culture for acid fast bacillus (AFB)

Tuberculin skin test

Answer and Explanation

The Correct Answer is D

A.   The BCG vaccine is a vaccine used to prevent tuberculosis (TB) disease. However, its effectiveness varies widely and is primarily used in countries with a high prevalence of TB. Therefore, administering the BCG vaccine is not typically part of the evaluation process for TB exposure in a client.
B.   A chest x-ray is commonly used to evaluate for active pulmonary TB disease. It can identify characteristic findings such as infiltrates, cavitations, or nodular lesions in the lungs that suggest TB infection. A chest x- ray is often performed as part of the initial evaluation for TB after exposure or to assess for active disease.
C.   Sputum culture for AFB is a definitive diagnostic test for tuberculosis. It involves collecting sputum samples and culturing them in a laboratory to detect the presence of Mycobacterium tuberculosis, the bacterium that causes TB.
D.   The tuberculin skin test (TST), also known as the Mantoux test, involves injecting a small amount of purified protein derivative (PPD) into the skin of the forearm. After 48-72 hours, a healthcare provider assesses the size of the induration (swelling) at the injection site. A positive TST indicates exposure to TB but does not differentiate between latent TB infection (LTBI) and active TB disease.

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Correct Answer is B

Explanation

A. Urinary frequency refers to the need to urinate more often than usual. It does not typically cause changes in the color, clarity, or odor of urine. It may be associated with conditions like urinary tract infections (UTIs) or other urinary issues but does not directly cause dark amber, cloudy, or foul-smelling urine.
B. A UTI is a common cause of changes in urine characteristics. Dark amber color can indicate concentrated urine due to dehydration or the presence of blood. Cloudiness suggests the presence of pus or bacteria, while an unpleasant odor can be due to bacterial growth. UTIs often cause these symptoms due to inflammation and infection of the urinary tract.
C. Urinary incontinence refers to involuntary loss of urine. It does not typically cause changes in the appearance or odor of urine unless it leads to urine pooling and subsequent bacterial growth, which could potentially cause odor. However, incontinence itself is not a direct cause of dark amber, cloudy urine with an unpleasant odor.
D. Urinary retention occurs when the bladder does not empty completely or at all. It can lead to concentrated urine (dark amber color) due to prolonged storage in the bladder. Cloudiness and an unpleasant odor can occur if there is bacterial growth in stagnant urine. Therefore, urinary retention can contribute to the observed urine characteristics.

A. Place the client in a high Fowler's position. B. Ambulate the client twice daily. C. Mark abdominal girth once daily. D. Irrigate the nasogastric tube with tap water.

Correct Answer is C

Explanation

A. A footboard is a device placed at the end of the bed and it's used to prevent the feet from dropping towards the bed while the patient is lying down.
B. While a footboard can provide some support and prevent the client's feet from hanging off the edge of the bed, its primary purpose is not to prevent pressure ulcers on the foot. Pressure ulcers are more likely to occur on bony prominences such as the heels or sacrum.

C. Plantar flexion refers to the downward flexing of the foot at the ankle joint. In immobile clients, prolonged plantar flexion can lead to contractures or foot drop. A footboard helps maintain the foot in a neutral or slightly dorsiflexed position, which helps prevent plantar flexion contractures.
D. A footboard is not typically used for isotonic exercises, which involve active movement against resistance. Instead, it serves a more passive role in maintaining foot position and preventing issues related to immobility.

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A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed- suction drains in place. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?

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