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:
The thickest part of the heart is not the upper chambers but the lower chambers, specifically the left ventricle. This is because it needs to pump blood to the entire body.
Choice B rationale:
Blood leaves the heart through the lower chambers, or ventricles, not the upper chambers.
Choice C rationale:
Blood enters the heart through the upper chambers, or atria. This is where deoxygenated blood from the body and oxygenated blood from the lungs first enter the heart.
Choice D rationale:
The term “ventricles” refers to the lower chambers of the heart, not the upper chambers.
Correct Answer is B
Explanation
Choice A rationale:
Initiating diuretic therapy is incorrect because it would further decrease the client’s already low calcium level.
Choice B rationale:
Implementing seizure precautions is correct because hypocalcemia can cause neuromuscular irritability and seizures.
Choice C rationale:
Preparing the client for hemodialysis is incorrect because it is not the first-line treatment for hypocalcemia.
Choice D rationale:
Administering phosphate is incorrect because it would further decrease the client’s already low calcium level.
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