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 B
Explanation
A. Symmetrical chest expansion: In a tension pneumothorax, chest expansion is usually asymmetrical because air trapped in the pleural space prevents full lung expansion on the affected side. Symmetrical movement would not be expected in this condition.
B. Tracheal deviation away from the affected side: This is a hallmark sign of tension pneumothorax. As intrapleural pressure increases, the mediastinum shifts, pushing the trachea and other structures toward the unaffected side, which is a medical emergency requiring immediate intervention.
C. Increased breath sounds on the affected side: Breath sounds are typically absent or markedly diminished over the affected lung due to lung collapse. Increased breath sounds would not occur in the presence of trapped air compressing the lung.
D. Hyperresonance to percussion on the affected side: Hyperresonance can occur with a simple pneumothorax due to excess air in the pleural cavity. However, while present, it is not as specific or critical as tracheal deviation, which directly indicates a tension pneumothorax.
Correct Answer is ["25"]
Explanation
Calculation:
Ordered infusion rate = 1,000 units/hour.
- Identify the available concentration of the solution.
Available concentration = Total units / Total volume
= 20,000 units / 500 mL
= 40 units/mL.
- Calculate the infusion pump setting in milliliters per hour (mL/hr).
Pump setting (mL/hr) = Ordered rate (units/hr) / Available concentration (units/mL)
= 1,000 units/hr / 40 units/mL
= 25 mL/hr.
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