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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Requesting a prescription for an analgesic for the client is a part of conventional medical treatment.
Choice B rationale:
Checking the client’s oxygen saturation level is a part of conventional medical treatment.
Choice C rationale:
Encouraging the client to take slow, deep breaths can help manage pain and is a holistic nursing approach.
Choice D rationale:
Obtaining blood work from the client is a part of conventional medical treatment.
Correct Answer is ["B","C","E"]
Explanation
The correct answers are Choice B: "I must stop smoking.", Choice C: "I am limiting my intake of fast foods.", and Choice E: "I need to monitor my weight."
Choice A rationale:
Stopping alcohol consumption can have various health benefits, but moderate alcohol consumption is not a primary risk factor for coronary artery disease. Instead, excessive drinking is more concerning.
Choice B rationale:
Smoking is a significant risk factor for coronary artery disease. Quitting smoking greatly reduces the risk and improves overall cardiovascular health.
Choice C rationale:
Limiting fast food intake is an important dietary change, as fast foods are often high in unhealthy fats, salt, and calories, which can contribute to coronary artery disease.
Choice D rationale:
The statement "I should lower my HDL cholesterol level" is incorrect. HDL cholesterol is considered "good" cholesterol and helps to protect against heart disease. Therefore, lowering HDL cholesterol would not be beneficial.
Choice E rationale:
Monitoring and maintaining a healthy weight is crucial for reducing the risk of coronary artery disease. Excess weight, particularly around the abdomen, is a known risk factor.
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