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:
Frozen dinners are often high in sodium, which can increase blood pressure, so they are not a good choice for someone with hypertension.
Choice B rationale:
Processed cheese products are also high in sodium, so they should be avoided.
Choice C rationale:
Seasoning food with herbs and spices is a healthy way to add flavor without adding sodium.
Choice D rationale:
Soy sauce is very high in sodium, so it should not be used as a marinade for meats.
Correct Answer is B
Explanation
Choice A rationale:
While calling 911 is important, it is not the first action the nurse should take. The nurse should first assess the victim’s condition.
Choice B rationale:
The first action when someone is choking is to ask if they can speak. If they can speak, it means air is still passing through the windpipe.
Choice C rationale:
The jaw-thrust maneuver is used to open the airway in an unconscious victim, not in a choking victim.
Choice D rationale:
Abdominal thrusts (Heimlich maneuver) are used when the victim cannot speak, indicating a complete airway obstruction.
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