Which nursing assessment indicates a positive reading of a tuberculin (TB) skin test?

1 day after injection with a 10-mm area of redness and swelling

2 days after injection with a 5-mm area of redness and swelling

4 days after injection with a 3-mm area of redness and swelling

5 days after injection with a 2-mm area of redness and swelling

Answer and Explanation

The Correct Answer is A

A. 1 day after injection with a 10-mm area of redness and swelling:

This may suggest a positive reading, but induration size is the primary criterion for interpretation, not just redness and swelling.

B. 2 days after injection with a 5-mm area of redness and swelling:

Similar to option A, a 5-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. Again, without information on the size of the induration, we cannot determine if this reading is positive.

C. 4 days after injection with a 3-mm area of redness and swelling:

Once more, a 3-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. As with the previous options, the size of the induration is the critical factor for interpretation.

D. 5 days after injection with a 2-mm area of redness and swelling:

As with the other options, a 2-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. The presence and size of induration are essential for accurate interpretation.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Encourage the client to drink 8 glasses of water a day.

This is the correct choice. Clients with COPD often have thickened respiratory secretions due to chronic inflammation and mucus production. Adequate hydration helps to keep these secretions thin, making them easier to cough up and clear from the airways. Encouraging the client to drink plenty of fluids, such as water, can assist in maintaining optimal hydration levels and promoting effective airway clearance.

B. Instruct the client to cough every 4 hours.

Instructing the client to cough on a scheduled basis, such as every 4 hours, is not appropriate for managing COPD. While coughing is important for clearing respiratory secretions, the frequency of coughing should be based on the client's individual needs and symptoms. Some clients with COPD may need to cough more frequently, while others may need to cough less often. It's important to encourage the client to cough as needed to clear secretions rather than on a predetermined schedule.

C. Provide the client with a low-protein diet.

Providing the client with a low-protein diet is not recommended for managing COPD. Adequate protein intake is important for maintaining muscle strength, including respiratory muscles, and supporting overall health. Clients with COPD may have increased energy needs due to the increased work of breathing and should be encouraged to consume a balanced diet that includes adequate protein.

D. Advise the client to lie down after eating.

Advising the client to lie down after eating is not recommended for managing COPD. Lying down after eating can increase pressure on the diaphragm and make breathing more difficult, especially for individuals with compromised lung function. It's generally recommended for individuals with COPD to remain in an upright position after eating to minimize respiratory discomfort and reduce the risk of aspiration.

A. Assign health care personnel to nondirect care activities for 24 hr after developing influenza symptoms. B. Place restrictions on visitation. C. Implement airborne precautions for clients who have influenza. D. Provide prophylactic antibiotics for clients who have been exposed to influenza

Correct Answer is B

Explanation

A. Assign health care personnel to nondirect care activities for 24 hr after developing influenza symptoms.

While it's important for healthcare personnel to stay home when they have influenza symptoms to prevent transmission to residents and coworkers, restricting them to nondirect care activities for only 24 hours may not be sufficient. Healthcare personnel with influenza symptoms should follow institutional policies regarding sick leave and clearance to return to work, which typically involve staying home until they are no longer contagious.

B. Place restrictions on visitation.

During an influenza outbreak in a long-term care facility, it's crucial to include interventions to prevent further spread of the virus. Placing restrictions on visitation helps reduce the risk of introducing the virus from outside sources into the facility. Visitors may inadvertently bring the influenza virus with them, potentially exposing vulnerable residents and staff members.

C. Implement airborne precautions for clients who have influenza.

Influenza is primarily transmitted through respiratory droplets rather than through airborne transmission. Airborne precautions are not typically necessary for managing influenza in a long-term care facility. Standard precautions, including hand hygiene, respiratory hygiene/cough etiquette, and use of personal protective equipment, are sufficient for preventing transmission.

D. Provide prophylactic antibiotics for clients who have been exposed to influenza.

Influenza is a viral infection and is not treated with antibiotics. Prophylactic antibiotics are not indicated for preventing influenza. Antiviral medications may be used for prophylaxis in certain high-risk individuals or in outbreak settings, but their use should be based on recommendations from public health authorities and healthcare providers, not blanket administration to all exposed individuals.

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Which nursing assessment indicates a positive reading of a tuberculin (TB) skin test?

Nursing Test Bank

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