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?

Choice A rationale:

Repeating the potassium level is not the first action to take. The nurse already has a recent lab value.

Choice B rationale:

The nurse should withhold the medication. The normal range for potassium is 3.5-5.0 mEq/L. A level of 5.5 mEq/L is high, so giving more potassium could lead to hyperkalemia.

Choice C rationale:

Monitoring for paresthesia is important in hyperkalemia, but it is not the first action. The nurse should first prevent further increase in potassium levels.

Choice D rationale:

Administering a hypertonic solution is not relevant in this situation. It does not directly address the high potassium level.

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.