A nurse is assessing a client who received a Mantoux skin test 72 hr ago for tuberculosis screening. Which of the following findings indicates a positive test result?
A blister-like area
A cool, blanched area
An elevated, hardened area
An area of ecchymosis
The Correct Answer is C
Rationale:
A. A blister-like area: Blistering is not the expected reaction used to interpret a Mantoux test. The result is based on the presence and size of induration, not the formation of blisters.
B. A cool, blanched area: Coolness and blanching are not indicators of a positive test. These findings may reflect poor circulation or local skin reaction unrelated to tuberculosis screening.
C. An elevated, hardened area: Induration (elevated, firm area) at the injection site, measured in millimeters, is the basis for determining a positive result. The size threshold for positivity depends on the client’s risk factors for tuberculosis.
D. An area of ecchymosis: Bruising at the site is a local skin reaction that can occur after any injection and is unrelated to the diagnostic criteria for a positive Mantoux test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Serum potassium: Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. Monitoring serum potassium is essential to detect elevated levels early and prevent cardiac complications.
B. Platelet count: Spironolactone does not significantly affect platelet production or function, so routine monitoring of platelets is not indicated for this medication.
C. Urine ketones: Ketone monitoring is relevant for clients with uncontrolled diabetes or ketosis, but it is not related to spironolactone therapy.
D. Total bilirubin: Bilirubin levels are used to assess liver function, which is not directly affected by spironolactone in most clients, so routine monitoring is not necessary unless the client has underlying hepatic disease.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
Rationale:
- Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: The nurse should follow the ordered transfusion rate and not titrate it based on blood pressure. The priority is to transfuse the blood safely and at the prescribed rate, while monitoring the client's response. Blood pressure will improve as the blood volume is restored.
- Obtain the first unit of packed RBCs from the blood bank: This is necessary to correct the client’s anemia (Hgb 9.1 g/dL, Hct 27%) and address the suspected acute blood loss indicated by positive hemoccult stool and hemodynamic changes.
- Document the blood product transfusion in the client's medical record: Accurate documentation ensures legal compliance, tracks the administration, and records the client’s response, including any adverse events, supporting continuity of care.
- Stay with the client for the first 15 min of the transfusion: Most transfusion reactions occur during the first 15 minutes. Close observation allows for immediate intervention if the client develops fever, hypotension, or other adverse effects.
- Start an IV bolus of lactated Ringer's solution: Lactated Ringer’s contains calcium which can cause clotting in the transfusion line. Using LR can lead to hemolysis or transfusion complications. Only 0.9% sodium chloride should be used for flushing or running alongside blood transfusions.
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