Nokea
The nurse is preparing to perform a Mantoux tuberculin skin test. Which interventions apply to the administration of this test? Select all that apply.
- A. Explain the procedure to the client.
- B. Obtain a 3-mL syringe with a 1/2-inch needle for the injection.
- C. Mark the test area to locate it for reading 48 to 72 hours after injection.
- D. Bunch up the skin and insert the needle with the needle bevel facing downward.
- E. Cleanse the injection site on the lower dorsal surface of the forearm with alcohol and allow it to dry.
- F. Ask the client about a history of receiving a positive purified protein derivative (PPD) reaction.
Correct Answer: A,C,E,F
Rationale: The nurse should always explain the procedure to the client and then assess him or her for a history of a PPD reaction. The test should not be administered if the client has such a history. The nurse should use a tuberculin syringe (not a 3-mL syringe) with a 1/2-inch 26- or 27-gauge needle. The injection site on the lower dorsal surface of the forearm is cleansed with alcohol and allowed to dry. The skin is stretched taut, and 0.1 mL of solution containing 0.5 tuberculin units of PPD is injected. The injection is made just under the surface of the skin with the needle bevel facing upward to provide a discrete elevation of the skin (a wheal) 6 to 10 mm in diameter. The test area is marked to locate it for reading and the test area is read 48 to 72 hours after injection.
You may also like to solve these questions
Assessment of a nulligravid client in active labor reveals the following: complaints of moderate discomfort; cervix dilated $3 \mathrm{~cm}, 0$ station and completely effaced; fetal heart rate of $136 \mathrm{bpm}$. Which of the following should the nurse plan to do next?
- A. Assist the client with comfort measures and breathing techniques.
- B. Turn the client from the left side-lying position to the right side-lying position.
- C. Prepare the client for epidural anesthesia to relieve pain.
- D. Instruct the client that internal fetal monitoring is necessary.
Correct Answer: A
Rationale: Moderate discomfort in early labor is managed with non-pharmacologic comfort measures and breathing techniques to promote coping.
The client with borderline personality disorder spends much time around the nurse's station, making numerous minor requests. The nurse interprets these behaviors as indicating which of the following?
- A. Fears of abandonment and attention seeking
- B. Enjoyment of bothering the staff
- C. Boredom suggesting the need for something to do
- D. Lack of desire for involvement in milieu activities
Correct Answer: A
Rationale: Frequent requests and presence at the nurse's station in borderline personality disorder often reflect fears of abandonment and attention-seeking behaviors, characteristic of the disorder.
A client with a history of seizures is prescribed phenytoin (Dilantin). Which laboratory value should the nurse monitor?
- A. Liver function tests
- B. Renal function tests
- C. Complete blood count
- D. Electrolytes
Correct Answer: A
Rationale: Phenytoin can cause hepatotoxicity, so liver function tests should be monitored regularly to detect potential liver damage early.
A 1-year-old is brought to the clinic with failure to thrive. Which assessment should the nurse prioritize?
- A. Dietary intake history
- B. Motor milestone development
- C. Head circumference
- D. Skin turgor
Correct Answer: A
Rationale: Dietary intake history is critical in failure to thrive to identify inadequate caloric intake or feeding issues, guiding intervention.
Which of the following outcomes is most appropriate for a nursing diagnosis of Ineffective tissue perfusion related to interruption of arterial flow? Select all that apply.
- A. Extremities warm to touch.
- B. Improved respiratory status.
- C. Decreased muscle pain with activity.
- D. Participation in self-care measures.
- E. Lungs clear to auscultation.
Correct Answer: A,C,D
Rationale: Warm extremities, reduced muscle pain, and self-care participation indicate improved perfusion; respiratory outcomes are unrelated.