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:
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.
Correct Answer is A
Explanation
Choice A rationale:
The medication should be dropped into the conjunctival sac, which is the space between the lower eyelid and the eyeball. This is the correct method for administering ophthalmic drops.
Choice B rationale:
The eyedropper should not touch any part of the eye, including the sclera, to avoid contamination and potential infection.
Choice C rationale:
It is not necessary to don sterile gloves when administering ophthalmic drops. Clean gloves or hand hygiene is sufficient.
Choice D rationale:
Rubbing the eye after instilling medication can cause irritation and may disperse the medication, reducing its effectiveness.
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