A client receives a positive Mantoux tuberculin skin test with an induration measuring 12 mm. The client is asymptomatic and has no history of prior tuberculosis (TB) exposure or vaccination. Which action should the nurse anticipate next?
Schedule a chest x-ray to evaluate for active pulmonary tuberculosis
Instruct the client to begin a full course of antitubercular medications immediately
Repeat the Mantoux test in 3 months to confirm the result
Document the result as negative since the client has no symptoms
The Correct Answer is A
A. Schedule a chest x-ray to evaluate for active pulmonary tuberculosis: A positive Mantoux test with induration ≥10 mm in a client without prior TB exposure indicates possible latent TB infection. A chest x-ray is necessary to rule out active disease before initiating treatment and to guide further management.
B. Instruct the client to begin a full course of antitubercular medications immediately: Starting treatment without confirming whether the infection is latent or active could be inappropriate and may lead to unnecessary drug exposure and side effects. Confirmation through imaging and possibly further testing is required first.
C. Repeat the Mantoux test in 3 months to confirm the result: Repeating the test is not necessary because an induration of 12 mm already meets the criteria for a positive result in most adults. Delaying further evaluation could postpone appropriate diagnosis and management.
D. Document the result as negative since the client has no symptoms: Absence of symptoms does not rule out latent tuberculosis. Documenting the result as negative would be inaccurate and could delay treatment or preventive measures, increasing the risk of future disease activation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I can get a supply of the medication for 60 days at a time": Clozapine requires frequent blood monitoring because of the risk of agranulocytosis. Clients are usually dispensed only a 1–2 week supply at a time depending on lab results.
B. "I may have a fatal response if I go outside and develop a rash": Clozapine is not associated with fatal skin reactions from sunlight exposure, its most critical concern is blood dyscrasias such as agranulocytosis.
C. "I need to have monthly cytokines tests for up to a year": Clients on clozapine require weekly complete blood counts (CBCs) for the first 6 months, then every 2 weeks for the next 6 months, and monthly only after a year if stable. Cytokine testing is not part of clozapine monitoring.
D. "I should call the health care provider if I develop a sore throat and fever": Sore throat and fever may signal agranulocytosis or severe neutropenia, which are potentially life-threatening side effects of clozapine. Prompt reporting ensures early intervention.
Correct Answer is D
Explanation
A. Administration of oxygen is contraindicated in clients who are using bronchodilators: Oxygen therapy is not contraindicated with bronchodilators. In fact, bronchodilators and oxygen are commonly used together to relieve airway obstruction and improve gas exchange in COPD.
B. High oxygen concentrations will cause coughing and dyspnea: While oxygen therapy can sometimes dry airways or cause minor irritation, coughing and dyspnea are not direct effects of high oxygen concentration. Dyspnea in COPD is due to impaired gas exchange and airflow limitation.
C. Increased oxygen use will cause the client to become dependent on the oxygen: Oxygen therapy does not create physical dependence. Clients with COPD may require long-term oxygen due to disease progression, but this is related to their chronic hypoxemia rather than dependency.
D. High oxygen concentration may inhibit the hypoxic stimulus to breathe: Clients with COPD often rely on hypoxemia as their primary drive to breathe, since chronic CO₂ retention blunts the normal hypercapnic drive. Administering high oxygen concentrations can suppress this hypoxic drive, leading to hypoventilation and CO₂ narcosis.
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