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:
Tilt the head and lift the chin is a technique used to open the airway in an unconscious client, not a conscious one with an airway obstruction.
Choice B rationale:
Turning the client to the side is not the first action to take when a client is conscious and has an airway obstruction.
Choice C rationale:
The Heimlich maneuver is the appropriate action to take for a conscious client who has an airway obstruction. It works by creating an artificial cough, intended to force the obstruction out.
Choice D rationale:
A blind finger sweep should never be performed because it can push the obstruction further into the airway.
Correct Answer is B
Explanation
Choice A rationale:
Metabolic acidosis would likely present with rapid, deep breathing (Kussmaul respirations), not slow and shallow breathing.
Choice B rationale:
The client’s symptoms of vomiting (which can cause a loss of stomach acid), dizziness, palpitations, and numbness and tingling in the extremities and around the mouth are consistent with metabolic alkalosis.
Choice C rationale:
Respiratory alkalosis would likely present with rapid breathing, not slow and shallow breathing.
Choice D rationale:
Respiratory acidosis would likely present with rapid, shallow breathing, not slow and shallow breathing.
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