A nurse is assessing a client who received a Mantoux skin test 72 hours ago for tuberculosis screening. Which of the following findings indicates a positive test result?

Choice A reason: Supine positioning risks respiratory strain post-myocardial infarction; semi-Fowler’s is preferred. Cardiac rehabilitation is appropriate. Assuming supine is correct risks discomfort or complications, critical to avoid in ensuring proper positioning and recovery support for clients 3 days post-acute myocardial infarction.

Choice B reason: ECG every 12 hours is excessive 3 days post-myocardial infarction unless symptomatic; daily or as-needed is standard. Rehabilitation consultation is key. Assuming frequent ECGs risks unnecessary testing, critical to prevent in focusing on recovery planning and rehabilitation for post-infarction clients.

Choice C reason: Troponin levels every 4 hours are unnecessary 3 days post-myocardial infarction, as levels peak earlier; rehabilitation is priority. Assuming frequent troponin checks risks redundant testing, critical to avoid in ensuring appropriate care focus on recovery and rehabilitation post-acute myocardial infarction.

Choice D reason: Obtaining a cardiac rehabilitation consultation 3 days post-myocardial infarction supports recovery through structured exercise and education, critical for preventing further events. This intervention promotes long-term cardiac health, essential for reducing readmissions, enhancing recovery, and improving quality of life in post-infarction clients.

Choice A reason: Increased blood pressure is not an effect of furosemide, which reduces fluid volume, lowering pressure. Weight loss indicates efficacy. Assuming increased pressure is correct risks misinterpreting diuresis, potentially delaying further fluid management, critical to avoid in treating fluid volume excess effectively.

Choice B reason: Decreased pain is unrelated to furosemide’s diuretic action, which targets fluid reduction, evidenced by weight loss. Assuming pain reduction is an indicator risks missing fluid status changes, critical to prevent in ensuring accurate assessment of furosemide’s effectiveness in fluid volume excess treatment.

Choice C reason: Decreased inflammation is not a furosemide effect; it promotes diuresis, reducing fluid, shown by weight loss. Assuming inflammation reduction is relevant risks misjudging medication efficacy, potentially overlooking fluid overload signs, critical to avoid in managing fluid volume excess with diuretic therapy.

Choice D reason: Weight loss indicates furosemide’s effectiveness, as it reduces fluid volume excess through diuresis, decreasing edema and body weight. This is critical for assessing therapeutic response, ensuring fluid balance, preventing complications like heart failure, and guiding further treatment in clients with fluid overload.