The 79-year-old patient with bacterial pneumonia becomes increasingly restless and confused. Temperature is 100° F and pulse, blood pressure, and respirations are elevated since the last assessment 6 hours ago. The initial intervention by the nurse should be to:

administer an NSAID for discomfort

assess the patient's 02 saturation

check the MAR for an order for a mild sedative

take the patient off of oral fluids

Answer and Explanation

The Correct Answer is B

A. Administer an NSAID for discomfort: While fever and discomfort may contribute to restlessness, NSAIDs do not address the most urgent concern, which is potential hypoxia. Treating symptoms without first assessing respiratory function may delay appropriate intervention.

B. Assess the patient's O₂ saturation: Increasing restlessness and confusion in a pneumonia patient can be early signs of hypoxia, especially in older adults. Oxygen saturation should be evaluated immediately to determine if the patient needs supplemental oxygen or further respiratory support.

C. Check the MAR for an order for a mild sedative: Sedatives may worsen confusion and can depress respiratory drive, particularly in hypoxic patients. Administering a sedative without first ruling out hypoxia may pose significant risk.

D. Take the patient off of oral fluids: Unless there are clear signs of aspiration or decreased level of consciousness, discontinuing oral fluids is not an appropriate first step. Hydration is important in pneumonia to help thin secretions and support recovery.

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Correct Answer is A

Explanation

A. Sputum culture for AFB: A sputum culture for acid-fast bacilli (AFB) is the definitive diagnostic test for active tuberculosis. It confirms the presence of Mycobacterium tuberculosis by identifying and culturing the bacteria from sputum, which is the most reliable confirmation of disease.

B. Chest x-ray: A chest x-ray can show lung abnormalities consistent with TB, such as cavitations or infiltrates, but it cannot confirm active infection. It is useful for supporting diagnosis but must be interpreted alongside microbiological tests.

C. Mantoux test: The Mantoux (PPD) test identifies TB exposure by measuring delayed hypersensitivity, but it does not distinguish between latent and active infection. A positive result requires further testing to confirm active disease.

D. Pulmonary function test: Pulmonary function tests assess lung capacity and airflow but are not used for diagnosing tuberculosis. They may be used later to evaluate lung impairment but have no role in confirming TB.

Correct Answer is ["3"]

Explanation

Children with the common cold are generally most contagious during the early stages of the illness typically within the first 2 to 3 daysafter symptoms appear. This is when viral shedding is at its peak, even if the child’s symptoms are mild. Hand hygiene, covering coughs, and limiting contact with others during the early days are essential to prevent spread.

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The 79-year-old patient with bacterial pneumonia becomes increasingly restless and confused. Temperature is 100° F and pulse, blood pressure, and respirations are elevated since the last assessment 6 hours ago. The initial intervention by the nurse should be to:

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Naxlex Comprehensive Predictor Exams

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis?

Correct Answer is A

Explanation

The mother of a child with a cold asks the nurse. "How long will my child be contagious?". The nurse should reply?

Correct Answer is ["3"]

Explanation

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