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:

Checking for a positive Chvostek’s sign is not relevant. This sign is associated with hypocalcemia, not with the lab values provided.

Choice B rationale:

The nurse should request a potassium replacement. The normal range for potassium is 3.5-5.0 mEq/L. A level of 3.0 mEq/L is low, indicating hypokalemia.

Choice C rationale:

Administering glucagon IM is not appropriate. The glucose level is within the normal range (70-110 mg/dL), so there is no need for glucagon.

Choice D rationale:

Discontinuing the TPN infusion is not the first action. The nurse should address the abnormal lab value (low potassium) first.

A. Respiratory acidosis. B. Metabolic acidosis. C. Respiratory alkalosis. D. Metabolic alkalosis.

Correct Answer is D

Explanation

Choice A rationale:

Respiratory acidosis is characterized by a high PaCO2 and a low pH. The client’s ABG results do not match this pattern.

Choice B rationale:

Metabolic acidosis is characterized by a low HCO3 and a low pH. The client’s ABG results do not match this pattern.

Choice C rationale:

Respiratory alkalosis is characterized by a low PaCO2 and a high pH. The client’s ABG results do not match this pattern.

Choice D rationale:

Metabolic alkalosis is characterized by a high HCO3 and a high pH. The client’s ABG results match this pattern. Normal values for pH, PaCO2, and HCO3 are 7.35-7.45, 35-45 mm Hg, and 22-26 mEq/L respectively.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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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?