The client diagnosed with pneumonia develops pleuritic chest pain. Which nursing action should the nurse implement at this time?

Notify the physician immediately.

Increase the oxygen from 2 to 4 liters/minute.

Teach about splinting the chest when coughing.

Obtain an electrocardiogram.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Notifying the physician immediately is not the first action to take. While it is important to keep the physician informed, the nurse should first implement measures to alleviate the client’s pain and discomfort.

Choice B reason:

Increasing the oxygen from 2 to 4 liters/minute may be necessary if the client is experiencing hypoxia, but it is not directly related to managing pleuritic chest pain. The primary focus should be on pain relief and comfort.

Choice C reason:

Teaching about splinting the chest when coughing is the most appropriate action. Splinting helps to reduce pain by stabilizing the chest wall during coughing, which can be particularly painful for clients with pleuritic chest pain.

Choice D reason:

Obtaining an electrocardiogram (ECG) is not immediately necessary for managing pleuritic chest pain caused by pneumonia. An ECG may be indicated if there are concerns about cardiac issues, but it is not the primary intervention for pleuritic pain.

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Correct Answer is A

Explanation

The tuberculin skin test (TST), also known as the Mantoux test, is used to determine if a person has been infected with the tuberculosis (TB) bacteria. The test involves injecting a small amount of purified protein derivative (PPD) into the skin of the forearm. The injection site is then examined 48 to 72 hours later for a reaction, which is measured in millimeters of induration (swelling).

Choice A reason:

Sunday morning is the correct time to read the test results. Since the test was administered on Thursday at 1200, the 48 to 72-hour window for reading the results would fall between Saturday at 1200 and Monday at 1200. Reading the results on Sunday morning falls within this time frame, making it the appropriate choice.

Choice B reason:

Saturday morning is not the correct time to read the test results. Reading the test results on Saturday morning would be less than 48 hours after the test was administered, which is too early to accurately assess the reaction. The test needs to be read between 48 and 72 hours after administration to ensure accurate results.

Choice C reason:

Friday morning is also not the correct time to read the test results. Reading the test results on Friday morning would be only 24 hours after the test was administered, which is far too early. The immune response to the PPD injection takes time to develop, and reading the test too early can result in a false-negative result.

Choice D reason:

Monday morning is within the acceptable time frame to read the test results, but it is at the very end of the 72-hour window. While it is still technically correct, it is generally recommended to read the test closer to the 48-hour mark to ensure the most accurate results. Therefore, Sunday morning is a better choice.

A. Red-colored urine B. Black-colored stools C. Constipation D. Staining of teeth

Correct Answer is A

Explanation

Choice A reason: Red-colored urine is a common and expected side effect of rifampin. This medication can cause a reddish-orange discoloration of bodily fluids, including urine, sweat, saliva, and tears. This effect is harmless but can be alarming to patients if they are not forewarned. It is important for the nurse to inform the client about this side effect to prevent unnecessary concern.

Choice B reason: Black-colored stools are not typically associated with rifampin. Black stools can indicate gastrointestinal bleeding, which is a serious condition that requires immediate medical attention. This side effect is more commonly linked to medications like iron supplements or bismuth-containing compounds.

Choice C reason: Constipation is not a common side effect of rifampin. While gastrointestinal disturbances such as nausea, vomiting, and diarrhea can occur, constipation is not typically associated with this medication.

Choice D reason: Staining of teeth is not a known side effect of rifampin. This side effect is more commonly associated with medications like tetracycline antibiotics, which can cause discoloration of teeth, especially in children.

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The client diagnosed with pneumonia develops pleuritic chest pain. Which nursing action should the nurse implement at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a tuberculin (PPD) skin test on Thursday at 1200. The nurse documents on the medication record that the results need to be read:

Correct Answer is A

Explanation

A nurse is caring for a client who has active pulmonary tuberculosis (TB) and a new prescription for IV rifampin. The nurse should instruct the client that they should expect to experience which of the following manifestations while taking this medication?

Correct Answer is A

Explanation

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