A nurse is preparing to administer purified protein derivative (PPD) skin test to another healthcare worker. Which of the following statements about the test is incorrect?
You will need to return in 48-72 hours to have the test read
A positive skin test will mean you need to have a follow up a chest x-ray
"induration of greater than or equal to 10 millimeters means you have been exposed
"induration of greater than or equal to 10 millimeters means you have active tuberculosis
The Correct Answer is D
A. You will need to return in 48-72 hours to have the test read:
This statement is correct. The purified protein derivative (PPD) skin test, also known as the tuberculin skin test (TST), must be read within 48-72 hours after administration. If the test is not read within this timeframe, the results may not be valid, and the test may need to be repeated. The test evaluates the presence of induration (swelling) at the injection site, which indicates a delayed-type hypersensitivity reaction to the tuberculosis antigen.
B. A positive skin test will mean you need to have a follow-up chest x-ray:
This statement is correct. A positive PPD skin test indicates exposure to Mycobacterium tuberculosis (the bacteria that causes tuberculosis). However, a positive result does not necessarily mean the person has active tuberculosis. A follow-up chest x-ray is typically recommended to determine whether active TB disease is present. The chest x-ray helps to assess for signs of active infection, such as lung lesions.
C. "Induration of greater than or equal to 10 millimeters means you have been exposed":
This statement is correct. In the context of a PPD skin test, induration (raised area of the skin) of 10 millimeters or more is generally considered a positive result, indicating exposure to tuberculosis. However, the exact threshold for what is considered positive can vary based on individual risk factors. A positive test means the person has been exposed to the tuberculosis bacteria, but it does not confirm active disease.
D. "Induration of greater than or equal to 10 millimeters means you have active tuberculosis":
This statement is incorrect. A positive PPD skin test result indicates exposure to Mycobacterium tuberculosis, but it does not confirm active tuberculosis (TB) infection. The induration reflects prior exposure or latent infection. To determine if the individual has active TB, additional diagnostic tests such as a chest x-ray, sputum cultures, and possibly a molecular test are required. A positive PPD result does not differentiate between latent TB infection and active TB disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Obtaining a primary and secondary tubing set:
The primary tubing is used for the intravenous access, and the secondary tubing is attached for administering the blood product. This ensures that the blood transfusion will be delivered effectively, and it is a standard practice to use proper IV tubing for blood products to avoid contamination or complications.
B) Ensuring another licensed personnel is available:
. While it is required that two licensed healthcare professionals verify the blood product before starting the transfusion, this action itself is not contraindicated, it is required. Both individuals should independently check the patient's identification, blood type, and the matching of the blood product before administration. Therefore, the answer to the question should not be about ensuring availability of licensed personnel as this is actually a required safety measure, not contraindicated. The actual contraindications involve actions like using inappropriate fluids for transfusion or mismatching blood.
C) Obtaining 0.9% normal saline solution:
This is appropriate and necessary when preparing for a blood transfusion. Normal saline (0.9%) is the only compatible solution that should be used to flush the IV line before and after the transfusion or to prime the blood tubing. Other solutions, such as lactated Ringer's, can cause clotting when mixed with blood, making saline the only appropriate choice.
D) Checking ABO and Rh status of the donor and recipient:
This is essential and mandatory before administering a blood transfusion. It is critical to ensure that the ABO blood group and Rh factor of the donor and recipient are compatible to prevent hemolytic reactions. This compatibility check must be done every time before administering a transfusion, and it is an integral part of ensuring patient safety.
Correct Answer is C
Explanation
A) Instruct the patient to swallow the medication with the head tilted backwards:
Tilting the head backward while swallowing may worsen the patient's ability to swallow, especially if they are experiencing facial droop and slurred speech. This position could increase the risk of aspiration or choking. A safer approach involves evaluating the patient’s swallowing ability before giving any oral medications.
B) Place the medication in the back of the mouth on the affected side:
While placing the medication on the unaffected side might seem like an alternative to help with swallowing, it is still important to assess the patient's swallowing ability first. If the patient has difficulty swallowing due to neurological deficits, placing the medication on the affected side could increase the risk of aspiration, leading to complications such as pneumonia.
C) Evaluate the patient’s ability to swallow:
Evaluating the patient's ability to swallow is the most important initial action. Facial droop and slurred speech can indicate potential dysphagia or difficulty swallowing, which could lead to aspiration if medications are given orally without further assessment. The nurse must determine if the patient can swallow safely before administering any oral medications, including aspirin, to prevent complications.
D) Provide the patient with thickened liquids:
Thickened liquids may be helpful for patients with known dysphagia, but this approach is not suitable in this case because the first priority is assessing the patient's swallowing ability. Giving thickened liquids without evaluating swallowing could increase the risk of aspiration if the patient is unable to manage liquids safely. An evaluation should precede any interventions like thickening liquids.
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