A charge nurse is observing a nurse performing a Mantoux tuberculin skin test for a client.
Which of the following actions should prompt the charge nurse to intervene?

Creating a 6 mm (1/4 in) bleb in the intradermal space of the forearm.

Visualizing the tip of the needle under the skin.

Stretching the skin tightly before injection.

Withdrawing the needle and massages the site gently.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Creating a 6 mm (1/4 in) bleb in the intradermal space of the forearm is the correct procedure for a Mantoux tuberculin skin test.

Choice B rationale:

Visualizing the tip of the needle under the skin is the correct procedure for a Mantoux tuberculin skin test.

Choice C rationale:

Stretching the skin tightly before injection is the correct procedure for a Mantoux tuberculin skin test.

Choice D rationale:

Withdrawing the needle and massaging the site gently is incorrect. Massaging the site can cause the test solution to disperse, which can affect the test results.

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Correct Answer is B

Explanation

Choice A rationale:

While calling 911 is important, it is not the first action the nurse should take. The nurse should first assess the victim’s condition.

Choice B rationale:

The first action when someone is choking is to ask if they can speak. If they can speak, it means air is still passing through the windpipe.

Choice C rationale:

The jaw-thrust maneuver is used to open the airway in an unconscious victim, not in a choking victim.

Choice D rationale:

Abdominal thrusts (Heimlich maneuver) are used when the victim cannot speak, indicating a complete airway obstruction.

A. Metabolic alkalosis. B. Respiratory acidosis. C. Metabolic acidosis. D. Respiratory alkalosis.

Correct Answer is B

Explanation

Choice A rationale:

Metabolic alkalosis is incorrect because it would present with a high pH and high HCO3. This client’s pH is low, indicating acidosis, not alkalosis.

Choice B rationale:

Respiratory acidosis is correct. It is characterized by a low pH and high PaCO2, as seen in this client’s results. This condition occurs when the lungs can’t remove enough CO2, causing it to build up in the blood and lower the pH.

Choice C rationale:

Metabolic acidosis is incorrect because it would present with a low pH and low HCO3. This client’s HCO3 is normal.

Choice D rationale:

Respiratory alkalosis is incorrect because it would present with a high pH and low PaCO2. This client’s pH is low and PaCO2 is high.

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A charge nurse is observing a nurse performing a Mantoux tuberculin skin test for a client.Which of the following actions should prompt the charge nurse to intervene?

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Naxlex Comprehensive Predictor Exams

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Explanation

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A charge nurse is observing a nurse performing a Mantoux tuberculin skin test for a client.
Which of the following actions should prompt the charge nurse to intervene?