A charge nurse is observing a nurse performing a Mantoux tuberculin skin test for a client.
Which of the following actions should prompt the charge nurse to intervene?
Creating a 6 mm (1/4 in) bleb in the intradermal space of the forearm.
Visualizing the tip of the needle under the skin.
Stretching the skin tightly before injection.
Withdrawing the needle and massages the site gently.
The Correct Answer is D
Choice A rationale:
Creating a 6 mm (1/4 in) bleb in the intradermal space of the forearm is the correct procedure for a Mantoux tuberculin skin test.
Choice B rationale:
Visualizing the tip of the needle under the skin is the correct procedure for a Mantoux tuberculin skin test.
Choice C rationale:
Stretching the skin tightly before injection is the correct procedure for a Mantoux tuberculin skin test.
Choice D rationale:
Withdrawing the needle and massaging the site gently is incorrect. Massaging the site can cause the test solution to disperse, which can affect the test results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Bradycardia, or a slow heart rate, is not typically an early sign of circulatory overload.
Choice B rationale:
Dyspnea, or difficulty breathing, is an early sign of circulatory overload. This occurs because the heart is unable to pump the excess blood effectively, leading to fluid buildup in the lungs.
Choice C rationale:
Flushing, or reddening of the skin, is not typically an early sign of circulatory overload.
Choice D rationale:
Vomiting is not typically an early sign of circulatory overload.
Correct Answer is B
Explanation
Choice A rationale:
Placing the client in a modified Trendelenburg position is not the first action to take when managing a heavily bleeding wound.
Choice B rationale:
Applying direct pressure to the wound is the first action to take to control bleeding.
Choice C rationale:
Elevating the extremity can help control bleeding, but it is not the first action to take.
Choice D rationale:
Applying a tourniquet is a last resort when other methods of controlling bleeding have failed.
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