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:
Changing soiled linens daily is important, but it is not the most effective way to prevent the spread of pathogens.
Choice B rationale:
Hand hygiene is the single most effective way to prevent the spread of pathogens. It should be performed before and after every client interaction, before and after any procedure, and after any contact with potentially infectious material.
Choice C rationale:
Discarding used syringes in appropriate containers is important for safety, but it does not directly prevent the spread of pathogens.
Choice D rationale:
Properly disposing of contaminated equipment is important, but hand hygiene is more effective at preventing the spread of pathogens.
Correct Answer is A
Explanation
Choice A rationale:
Tachycardia, or a rapid heart rate, is a common early sign of hypovolemic shock as the body tries to compensate for the decreased blood volume by increasing the heart rate.
Choice B rationale:
Diminished urine output is a sign of hypovolemic shock, but it is not typically an early sign.
Choice C rationale:
Cold, clammy skin is a sign of hypovolemic shock, but it is not typically an early sign.
Choice D rationale:
Unconsciousness is a late sign of hypovolemic shock, indicating severe blood loss and inadequate perfusion to the brain.
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