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 C
Explanation
Choice A rationale:
This statement is incorrect. Veins do not carry oxygenated blood away from the heart, and arteries do not carry deoxygenated blood toward the heart.
Choice B rationale:
This statement is incorrect. While it is true that veins carry deoxygenated blood, they carry it toward the heart, not away from it. Similarly, arteries carry oxygenated blood, but they carry it away from the heart, not toward it.
Choice C rationale:
This statement is correct. In the circulatory system, veins carry deoxygenated blood toward the heart, while arteries carry oxygenated blood away from the heart.
Choice D rationale:
This statement is incorrect. Veins do not carry oxygenated blood toward the heart, and arteries do not carry deoxygenated blood away from the heart.
Correct Answer is B
Explanation
Choice A rationale:
Urine specific gravity 1.020 is within the normal range (1.005-1.030), so it does not indicate fluid volume deficit.
Choice B rationale:
Urine output 15 mL/hr is less than the normal minimum of 30 mL/hr, indicating fluid volume deficit.
Choice C rationale:
Hct 43% is within the normal range (38.8-50.0 for men, 34.9-44.5 for women), so it does not indicate fluid volume deficit.
Choice D rationale:
BUN 12 mg/dL is within the normal range (7-20 mg/dL), so it does not indicate fluid volume deficit.
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