A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take?

Perform a Mantoux skin test on the client.

Assign the client to a negative-pressure airflow room.

Wear a surgical mask when providing care to the client.

Recommend that the client's family members receive antiviral therapy.

Answer and Explanation

The Correct Answer is C

The correct answer is: c. Wear a surgical mask when providing care to the client.

Choice A: Perform a Mantoux skin test on the client

The Mantoux skin test is used to screen for tuberculosis, not pertussis. Pertussis, also known as whooping cough, is a bacterial infection caused by Bordetella pertussis. The Mantoux test would not be relevant or helpful in diagnosing or managing pertussis.

Choice B: Assign the client to a negative-pressure airflow room

Negative-pressure airflow rooms are typically used for airborne infections such as tuberculosis, measles, or varicella. Pertussis is primarily spread through respiratory droplets, not airborne transmission, so a negative-pressure room is not necessary.

Choice C: Wear a surgical mask when providing care to the client

Wearing a surgical mask is appropriate when caring for a client with pertussis. Pertussis is spread through respiratory droplets, and wearing a mask helps prevent the transmission of the bacteria to healthcare workers and other patients.

Choice D: Recommend that the client’s family members receive antiviral therapy

Antiviral therapy is not effective against pertussis, which is a bacterial infection. Instead, antibiotics such as azithromycin or erythromycin are used to treat pertussis and prevent its spread. Therefore, recommending antiviral therapy would not be appropriate.

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Correct Answer is B

Explanation

Choice A reason: The fluctuation of fluid in the water-seal chamber does not necessarily mean that the lung is fully re-expanded. The water-seal chamber's fluid level fluctuates with the client's breathing because it reflects the changes in intrathoracic pressure.

Choice B reason: The statement "Your breathing pattern causes this" is correct. The fluctuation, also known as tidaling, in the water-seal chamber is normal and occurs in response to the client's breathing. When the client inhales, negative pressure in the chest cavity causes the fluid level to rise, and when the client exhales, the pressure becomes positive, causing the fluid level to fall.

Choice C reason: Suction pressure that is too high can cause continuous bubbling in the suction control chamber but does not directly cause the fluid in the water-seal chamber to rise and fall. The suction control chamber's bubbling should be steady and gentle when the suction is set correctly.

Choice D reason: Continuous bubbling in the water-seal chamber may indicate an air leak, which is a problem that needs to be addressed. However, normal fluctuation with breathing is not indicative of an air leak.

A. Administer aspirin. B. Measure blood pressure. C. Administer nitroglycerin. D. Initiate IV access.

Correct Answer is C

Explanation

Choice A reason: Administering aspirin is one of the first interventions for a client experiencing acute angina because aspirin has antiplatelet properties that help prevent blood clots, which can reduce the risk of a heart attack.

Choice B reason: Measuring blood pressure is important but not the first action to take. It provides valuable information about the cardiovascular status of the client and can influence further treatment decisions.

Choice C reason: Administering nitroglycerin is a priority action for acute angina as it helps to dilate the coronary arteries and relieve chest pain. However, it is typically administered after aspirin unless contraindicated.

Choice D reason: Initiating IV access is an important step in the management of acute angina, as it allows for the administration of medications and fluids if needed. However, it is not the first action to take during an acute angina episode.

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A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take?

Choice A: Perform a Mantoux skin test on the client

Choice B: Assign the client to a negative-pressure airflow room

Choice C: Wear a surgical mask when providing care to the client

Choice D: Recommend that the client’s family members receive antiviral therapy

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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