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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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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Hypostatic pneumonia: The client's immobility due to paraplegia increases the risk of fluid accumulation in the lungs, leading to infection.
Immobility: Prolonged immobility is a significant risk factor for hypostatic pneumonia, as it impairs normal lung drainage and promotes bacterial growth

A. "There was a total of 10 sponges used during the procedure." B. "The client was intubated without complications." C. "The estimated blood loss was 250 milliliters." D. "The client is a member of the board of directors."

Correct Answer is C

Explanation

A. The number of sponges used during surgery is important but does not provide as much relevant information for postoperative care.

B. The intubation status is relevant to the immediate perioperative period, but the primary concern in hand-off is the current postoperative condition.

C. Estimated blood loss is an important clinical detail to convey during hand-off, as it may impact the client's recovery and need for monitoring.

D. The client’s position or professional role (e.g., being a board member) is not relevant to the care plan and should not be included in the hand-off report.

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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

A nurse is caring for a client in an acute care setting. Exhibits Complete the following sentence by using the list of options. The client is at risk for _________ as evidenced by _______.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

Correct Answer is C

Explanation

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A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?

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?

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A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?