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 C

Explanation

A. Turn off the ventilator alarms before suctioning the client's airway.

This choice is incorrect because it goes against standard practice. Ventilator alarms are critical for monitoring the patient's respiratory status and detecting any issues with the ventilator or the patient's airway. Turning off alarms before suctioning can lead to missed alarms and potentially dangerous situations for the patient.

B. Provide mouth care every 10 to 12 hr with hydrogen peroxide.

This choice is incorrect because using hydrogen peroxide for mouth care is not recommended. Hydrogen peroxide can be irritating to the mucosa and may cause harm to the patient's oral tissues. Instead, gentle oral care with an appropriate solution, such as a mouthwash specifically designed for oral hygiene in ventilated patients, is preferred. Mouth care should also be provided more frequently than every 10 to 12 hours to maintain oral hygiene and prevent complications such as ventilator-associated pneumonia.

C. Place the head of the client's bed at 40° when supine.

This choice is correct. Proper positioning of the patient is crucial for optimizing ventilation and preventing complications such as aspiration and ventilator-associated pneumonia. Elevating the head of the bed to 40 degrees when the patient is in a supine position helps to minimize the risk of aspiration by promoting drainage of secretions away from the airway and improving lung expansion.

D. Reposition the client every 4 hr.

This choice is not directly related to care for clients receiving mechanical ventilation. While repositioning the patient every 4 hours is important for preventing pressure ulcers and maintaining skin integrity, it is not specific to mechanical ventilation care. However, it is still an important aspect of overall patient care, particularly for patients who are immobile or confined to bed for extended periods.

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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