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 D
Explanation
Choice A rationale:
Respiratory acidosis is characterized by a high PaCO2 and a low pH. The client’s ABG results do not match this pattern.
Choice B rationale:
Metabolic acidosis is characterized by a low HCO3 and a low pH. The client’s ABG results do not match this pattern.
Choice C rationale:
Respiratory alkalosis is characterized by a low PaCO2 and a high pH. The client’s ABG results do not match this pattern.
Choice D rationale:
Metabolic alkalosis is characterized by a high HCO3 and a high pH. The client’s ABG results match this pattern. Normal values for pH, PaCO2, and HCO3 are 7.35-7.45, 35-45 mm Hg, and 22-26 mEq/L respectively.
Correct Answer is ["1128"]
Explanation
The correct answer is 1420 mL.
Calculation:
Convert all intake to mL:
- 4 oz soda = 118 mL
- 12 oz water = 355 mL
- 1 cup gelatin = 237 mL
- 1/2 cup broth = 118 mL
- 300 mL IV fluid = 300 mL
Add all intake: 118 mL + 355 mL + 237 mL + 118 mL + 300 mL = 1128 mL
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