The nurse is caring for a 48-year-old-client admitted with complaints of fatigue and hemoptysis, but no other significant medical history. Social history includes smoking 1 pack/day x 20 years and occasional alcohol use. He denies taking any medication. The Mantoux test placed 72 hours earlier reveals an indurated area of 4 cm. Which action will the nurse plan to include in the care for this client?
Prepare to administer intravenous (IV) antibiotics
Prepare client for computerized.tomography (CT scan)
Prepare to start oxygen therapy
Place client in airborne isolation
The Correct Answer is D
The client's complaint of hemoptysis (coughing up blood) and a positive Mantoux test (4 cm induration) suggest the possibility of tuberculosis (TB) infection. TB is an airborne infectious disease, and placing the client in airborne isolation is necessary to prevent the spread of the infection to others.
Antibiotics may be used to treat tuberculosis, but the initial step would be to isolate the client and confirm the diagnosis before starting specific treatment.
A CT scan may be ordered to further evaluate the client's condition, but it is not the immediate action required in this case. Isolation and confirmation of the diagnosis take priority. While the client may require oxygen therapy based on their respiratory symptoms, it is not the primary action to take at this stage. Isolation and further evaluation are necessary before initiating specific treatments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
During triage in a disaster situation, a color tagging system is often used to prioritize and categorize the injured based on the severity of their injuries and the urgency of medical attention required. The colors commonly used in triage are:
● Green tag: Minor injuries that are non-urgent and can typically wait for medical treatment.
● Yellow tag: Injuries that are significant but not immediately life-threatening, requiring medical attention within a few hours.
● Red tag: Critical injuries that are life-threatening but still salvageable with prompt medical intervention.
● Black tag: Injuries that are severe and unsurvivable or incompatible with life. This tag is assigned to individuals who are deceased or have injuries that are beyond the resources available for treatment.
In the given scenario, the absence of breathing, absent radial pulse, prolonged capillary refill, and unresponsiveness indicate a critical condition with no signs of life. Therefore, a black tag would be assigned to this individual.
Correct Answer is D
Explanation
The client's complaint of hemoptysis (coughing up blood) and a positive Mantoux test (4 cm induration) suggest the possibility of tuberculosis (TB) infection. TB is an airborne infectious disease, and placing the client in airborne isolation is necessary to prevent the spread of the infection to others.
Antibiotics may be used to treat tuberculosis, but the initial step would be to isolate the client and confirm the diagnosis before starting specific treatment.
A CT scan may be ordered to further evaluate the client's condition, but it is not the immediate action required in this case. Isolation and confirmation of the diagnosis take priority. While the client may require oxygen therapy based on their respiratory symptoms, it is not the primary action to take at this stage. Isolation and further evaluation are necessary before initiating specific treatments.
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