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 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.
Correct Answer is B
Explanation
Choice A rationale:
While it’s important to start CPR as soon as possible, the AED should be attached as soon as it’s available.
Choice B rationale:
The American Heart Association recommends providing chest compressions at a rate of 100-120/min during CPR.
Choice C rationale:
Checking for a brachial pulse is not a priority during CPR. The focus should be on providing chest compressions and rescue breaths.
Choice D rationale:
The correct ratio of compressions to breaths during CPR is 30:2, not 50:2.
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