Page 1613 - Saunders Comprehensive Review For NCLEX-RN

574. Answer: 2

Rationale: The nurse who is in contact with a client with tuberculosis should wear
an individually fitted particulate respirator. The nurse also would wear gloves as per
standard precautions. The nurse wears a gown when the possibility exists that the
clothing could become contaminated, such as when giving a bed bath.
Test-Taking Strategy: Focus on the subject, precautions when caring for the client
with tuberculosis. Think about the nurse’s task, a bed bath. Knowing that the nurse
should wear a particulate respirator eliminates options 1 and 4. Knowledge of basic
standard precautions directs you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Implementation
Content Area: Foundations of Care: Infection Control
Health Problem: Adult Health: Respiratory: Tuberculosis
Priority Concepts: Infection; Safety
Reference: Potter et al. (2017), pp. 459-460.

575. Answer: 3

Rationale: The most common initial symptom in pulmonary embolism is chest
pain that is sudden in onset. The next most commonly reported symptom is
dyspnea, which is accompanied by an increased respiratory rate. Other typical
symptoms of pulmonary embolism include apprehension and restlessness,
tachycardia, cough, and cyanosis.
Test-Taking Strategy: Note the strategic word, most. Because pulmonary
embolism does not result from an infectious process or an allergic reaction, eliminate
options 1 and 2 first. To select between the correct option and option 4, look at them
closely. Option 4 states dyspnea when deep breaths are taken. Although dyspnea
commonly occurs with pulmonary embolism, dyspnea is not associated only with
deep breathing. Therefore, eliminate option 4.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Respiratory
Health Problem: Adult Health: Respiratory: Pulmonary Embolism
Priority Concepts: Gas Exchange; Perfusion
Reference: Ignatavicius, Workman, Rebar (2018), p. 618.

576. Answer: 1

Rationale: The client with HIV infection is considered to have positive results on
tuberculin skin testing with an area of induration larger than 5 mm. The client
without HIV is positive with an induration larger than 10 mm. The client with HIV is
immunosuppressed, making a smaller area of induration positive for this type of
client. It is possible for the client infected with HIV to have false-negative readings
because of the immunosuppression factor. Options 2, 3, and 4 are incorrect

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