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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Muscle twitching
Muscle twitching is not a typical manifestation of oxygen toxicity. Instead, muscle twitching may be indicative of other conditions such as electrolyte imbalances (e.g., hypocalcemia or hypomagnesemia), neuromuscular disorders, or overstimulation of the nervous system.
B. Metallic taste in mouth
A metallic taste in the mouth is not commonly associated with oxygen toxicity. Instead, a metallic taste in the mouth may occur as a side effect of certain medications, dental issues, or as a symptom of other medical conditions such as acid reflux or oral infections.
C. Facial flushing
Facial flushing is a characteristic finding in oxygen toxicity. When exposed to high levels of oxygen over an extended period, individuals may experience facial flushing due to the vasodilatory effects of oxygen on blood vessels. This dilation of blood vessels leads to increased blood flow to the face, resulting in flushing or reddening of the skin.
D. Periorbital edema
Periorbital edema, or swelling around the eyes, is not a typical manifestation of oxygen toxicity. Instead, periorbital edema may occur as a result of various other conditions such as allergies, sinusitis, or fluid retention. It is not directly related to exposure to high levels of oxygen.
Correct Answer is B
Explanation
A. Administer IV morphine.
IV morphine may be indicated to relieve pain and anxiety associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.
B. Begin oxygen therapy.
The priority intervention for a client who develops a pulmonary embolism is to begin oxygen therapy. Pulmonary embolism (PE) is a life-threatening condition characterized by a blockage in one or more of the pulmonary arteries, usually due to a blood clot. This blockage can lead to impaired gas exchange and decreased oxygenation of the blood, resulting in hypoxemia (low blood oxygen levels) and potentially leading to respiratory failure. Administering oxygen therapy promptly helps to improve oxygenation and support vital organ function. Therefore, it is the priority intervention to address the immediate respiratory distress associated with a pulmonary embolism.
C. Start an IV infusion of lactated Ringer's.
Intravenous fluid administration may be necessary to maintain hemodynamic stability and support perfusion in a client with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.
D. Initiate cardiac monitoring.
Cardiac monitoring is important to assess for signs of cardiac compromise or dysrhythmias associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.
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