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A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?

A reddened area measuring 10 mm

A reddened area measuring 5 mm

An induration measuring 5 mm

An induration measuring 10 mm

Answer and Explanation

The Correct Answer is D

A. A reddened area without induration is not a positive result.

B. A reddened area without induration is not considered positive.

C. An induration of 5 mm is positive only for high-risk groups (e.g., immunocompromised clients).

D. An induration measuring 10 mm is considered positive in most adults, indicating TB exposure.

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Correct Answer is C

Explanation

A. Draw blood specimens for culture and sensitivity: Incorrect. Blood cultures are not routinely required for cardiac catheterization.

B. Administer nitroglycerin 0.4 mg SL 30 min before the procedure: Incorrect. Nitroglycerin is not typically administered before a cardiac catheterization unless specifically ordered.

C. Obtain a CBC with differential: A complete blood count (CBC) is necessary before a cardiac catheterization to assess for potential bleeding risks, infection, or anemia.

D. Transport the client to radiology for a CT scan: Incorrect. Cardiac catheterization is performed in a specialized cardiac catheterization lab, not in radiology.

A. "I will monitor the client's blood glucose level every 8 hours." B. "I will hang a new bag of TPN and IV tubing every 24 hours." C. "I will increase the rate of the TPN infusion to ensure the correct amount is given." D. "I will obtain the client's weight every other day."

Correct Answer is B

Explanation

A. "I will monitor the client’s blood glucose level every 8 hours": Incorrect. Blood glucose should be monitored more frequently, typically every 4-6 hours, due to the risk of hyperglycemia.

B. "I will hang a new bag of TPN and IV tubing every 24 hours": This practice reduces the risk of infection associated with TPN, which is a high-risk therapy.

C. "I will increase the rate of the TPN infusion to ensure the correct amount is given": Incorrect. The TPN infusion rate should not be adjusted without a provider's order, as it can cause hyperglycemia or fluid overload.

D. "I will obtain the client’s weight every other day": Incorrect. Daily weights are necessary to monitor fluid status and nutritional effectiveness.

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A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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