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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Metabolic alkalosis is incorrect because it would present with a high pH and high HCO3. This client’s pH is low, indicating acidosis, not alkalosis.

Choice B rationale:

Respiratory acidosis is correct. It is characterized by a low pH and high PaCO2, as seen in this client’s results. This condition occurs when the lungs can’t remove enough CO2, causing it to build up in the blood and lower the pH.

Choice C rationale:

Metabolic acidosis is incorrect because it would present with a low pH and low HCO3. This client’s HCO3 is normal.

Choice D rationale:

Respiratory alkalosis is incorrect because it would present with a high pH and low PaCO2. This client’s pH is low and PaCO2 is high.

A. 108/60 mm Hg. B. 154/96 mm Hg. C. 164/104 mm Hg. D. 128/88 mm Hg.

Correct Answer is B

Explanation

The correct answer is choice B.

Choice A rationale:

A blood pressure of 108/60 mm Hg is considered normal, as it is less than 120/80 mm Hg.

Choice B rationale:

A blood pressure of 154/96 mm Hg falls into the category of stage 1 hypertension. Stage 1 hypertension is classified as a systolic blood pressure reading that falls between 130 and 139 mm Hg or a diastolic reading that is between 80 and 89 mm Hg.

Choice C rationale:

A blood pressure of 164/104 mm Hg is considered stage 2 hypertension, as the systolic blood pressure is 140 mm Hg or higher, or the diastolic pressure is 90 mm Hg or higher.

Choice D rationale:

A blood pressure of 128/88 mm Hg is considered elevated, as the systolic blood pressure ranges from 120 to 129 mm Hg and the diastolic blood pressure is below 80 mm Hg.

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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?

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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?