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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E","F"]
Explanation
A. Hemoglobin: Although an improvement in hemoglobin would be ideal, it may take more time to see a significant change after blood loss or transfusion. A rise in hemoglobin indicates that the body is recovering from blood loss, but it is not as immediate an indicator of improvement as other factors, such as heart rate or blood pressure stabilization.
B. Heart rate: A decrease in the heart rate toward the normal range (60-100 beats/min) indicates improvement in the client's condition. The initial heart rate of 120-128 beats/min (tachycardia) suggests the client may have been compensating for blood loss or pain. A more stable heart rate would suggest a response to treatment and improvement in their cardiovascular status.
C. Pain level: A reduction in pain score is an important indicator of recovery post-surgery. After an emergency cesarean birth, pain management is a critical aspect of recovery, and a reduction in pain intensity would suggest that the client is improving and responding well to pain management interventions.
D. Temperature: A normal temperature would suggest no infection or complications. However, temperature changes in the immediate postpartum period can be influenced by various factors (e.g., infection, hormonal changes, or recovery from surgery). It is not as immediate an indicator of recovery as heart rate or blood pressure.
E. Vaginal bleeding: A decrease in vaginal bleeding, especially after a cesarean, would indicate that bleeding is being effectively controlled and the uterus is contracting appropriately, reducing the risk of hemorrhage or complications like uterine atony.
F. Blood pressure: A return to normal blood pressure levels (e.g., closer to the pre-pregnancy baseline) would indicate that the client's circulatory status is stabilizing. The dropping blood pressure seen earlier (from 95/62 mm Hg to 85/48 mm Hg) indicated hypovolemic shock or a response to blood loss, so stabilization and an increase in blood pressure would be a positive sign.
Correct Answer is C
Explanation
A. Battery involves actual physical contact without consent.
B. Negligence refers to failing to provide appropriate care, leading to harm.
C. Assault occurs when a person is threatened with harm or offensive contact, creating fear, even if no physical contact occurs. Telling the client that a catheter will be inserted without consent can be perceived as a threat.
D. Libel is a false written statement that damages someone’s reputation.
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