A nurse is checking the forearm of a client who received a tuberculin skin test 48 hr ago. Which of the following findings at the injection site should indicate to the nurse a positive result?
Excoriation
Firmness
Ulceration
Bleeding
The Correct Answer is B
A. Excoriation. Excoriation (skin abrasion or scratching) does not indicate a positive tuberculin skin test. A positive reaction is determined by induration (firm swelling) rather than skin irritation or superficial damage. Scratching the site can cause redness, but this is not a diagnostic sign of tuberculosis exposure.
B. Firmness. A positive tuberculin skin test is identified by the presence of induration (firm, raised swelling) at the injection site, which is measured in millimeters. The size of induration considered positive depends on the client’s risk factors. For example, ≥5 mm is positive in immunocompromised individuals, ≥10 mm in high-risk populations, and ≥15 mm in individuals with no risk factors.
C. Ulceration. Ulceration is not a typical reaction to a tuberculin skin test. If ulceration occurs, it may indicate improper injection technique, irritation, or an allergic reaction, rather than a true positive result. The test should be repeated in such cases.
D. Bleeding. Minor pinpoint bleeding at the injection site may occur due to the needle puncture but does not indicate a positive result. The key indicator of a positive test is the presence of measurable induration, not redness, bruising, or bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hypertension. Filgrastim, a granulocyte colony-stimulating factor (G-CSF), primarily stimulates white blood cell production. While minor blood pressure fluctuations can occur, hypertension is not a common or significant adverse effect. Monitoring blood pressure is important, but sustained hypertension is not expected.
B. Fluid retention. Filgrastim does not typically cause significant fluid retention. Medications such as corticosteroids or certain chemotherapeutic agents are more likely to lead to fluid overload. While rare cases of capillary leak syndrome have been reported, general fluid retention is not a primary concern.
C. Bone pain. Bone pain is the most common adverse effect of filgrastim. The medication stimulates bone marrow activity, leading to increased production of neutrophils, which can cause discomfort in bones, particularly in long bones such as the femur and sternum. Pain is usually mild to moderate and can be managed with acetaminophen or NSAIDs if appropriate.
D. Hypokalemia. Filgrastim does not have a direct effect on potassium levels. Electrolyte imbalances are more commonly associated with diuretics, corticosteroids, or chemotherapy. Clients on filgrastim typically do not require routine potassium monitoring unless other risk factors are present.
Correct Answer is ["1"]
Explanation
Convert pounds to kilograms:
Conversion factor: 1 kg = 2.2 lb
=145 lb / 2.2 lb/kg
= 65.9 kg
Calculate the total daily dose:
Total daily dose (mg) = Weight (kg) × Dosage (mg/kg/day)
= 65.9 kg 3 mg/kg/day
= 197.7 mg/day
Calculate the dose per administration (divided into two doses):
Dose per administration (mg) = Total daily dose (mg) / Number of doses
=197.7 mg/day / 2 doses
= 98.85 mg/dose
Calculate the number of tablets per dose:
Number of tablets = Desired dose (mg) / Available dose (mg/tablet)
=98.85 mg/dose / 100 mg/tablet
= 0.9885 tablets
Round to the nearest whole number:
0.9885 tablets is 1 tablet
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