A nurse is preparing a client for intradermal tuberculin skin testing (TST). Which of the following statements should the nurse make?

“An indurated area of 4 millimeters indicates a positive result.”.

“The injection site will be evaluated within 24 hours.”.

“A positive result does not always indicate active disease.”.

“The test will not be administered if you have had a previous negative result.”. .

Answer and Explanation

The Correct Answer is C

Choice A rationale
An indurated area of 4 millimeters is not considered a positive result for tuberculin skin testing. The size of induration considered positive varies based on the individual’s risk factors and health status.
Choice B rationale
The injection site for a tuberculin skin test should be evaluated between 48 and 72 hours after administration, not within 24 hours. Evaluating it too early may not provide accurate results.
Choice C rationale

A positive result in a tuberculin skin test indicates that the person has been infected with TB bacteria, but it does not necessarily mean they have active TB disease. Further tests are needed to determine if the disease is active.
Choice D rationale
A previous negative result does not preclude the administration of a new tuberculin skin test. Individuals can be retested if there is a new risk of exposure or if it is required for medical or occupational reasons.

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Correct Answer is D

Explanation

Choice A rationale
Frothy sputum is more commonly associated with left-sided heart failure, where fluid backs up into the lungs. It is not a typical finding in right-sided heart failure.
Choice B rationale

Orthopnea, or difficulty breathing while lying flat, is more commonly associated with left-sided heart failure. Right-sided heart failure primarily affects the systemic circulation.
Choice C rationale
Dyspnea, or shortness of breath, can occur in both left-sided and right-sided heart failure. However, it is more prominently associated with left-sided heart failure.
Choice D rationale
Peripheral edema, or swelling in the legs and ankles, is a common finding in right-sided heart failure. It occurs due to the backup of blood in the systemic circulation, leading to fluid accumulation in the tissues.

A. Acetone breath. B. Fever. C. Serum glucose 800 mg/dL (74 to 106 mg/dL). D. Serum bicarbonate 15 mEq/L (21 to 28 mEq/L). E. Insidious onset.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale
Acetone breath is a characteristic symptom of diabetic ketoacidosis (DKA), not hyperosmolar hyperglycemic syndrome (HHS). In DKA, the body produces ketones, leading to a fruity or acetone-like breath odor. HHS, on the other hand, does not typically involve significant ketone production.
Choice B rationale
Fever can be a manifestation of HHS, often due to an underlying infection or illness that precipitates the hyperglycemic state. Infections are common triggers for HHS, leading to elevated body temperature.
Choice C rationale
Serum glucose levels of 800 mg/dL are indicative of HHS. HHS is characterized by extremely high blood glucose levels, often exceeding 600 mg/dL, without significant ketoacidosis.
Choice D rationale
Serum bicarbonate levels of 15 mEq/L are more indicative of DKA rather than HHS. In HHS, bicarbonate levels are usually within the normal range because there is no significant ketoacidosis.
Choice E rationale
Insidious onset is a hallmark of HHS. The condition develops gradually over days to weeks, unlike DKA, which has a more rapid onset.

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A nurse is preparing a client for intradermal tuberculin skin testing (TST). Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is providing care for an older adult client who has hyperglycemia, polydipsia, and polyuria. Which of the following manifestations supports the clinical presentation of hyperosmolar hyperglycemic syndrome (HHS)? (Select All that Apply.)

Correct Answer is ["B","C","E"]

Explanation

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