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

A blister-like area

A cool, blanched area

An elevated, hardened area

An area of ecchymosis

Answer and Explanation

The Correct Answer is C

Rationale:

A. A blister-like area: Blistering is not the expected reaction used to interpret a Mantoux test. The result is based on the presence and size of induration, not the formation of blisters.

B. A cool, blanched area: Coolness and blanching are not indicators of a positive test. These findings may reflect poor circulation or local skin reaction unrelated to tuberculosis screening.

C. An elevated, hardened area: Induration (elevated, firm area) at the injection site, measured in millimeters, is the basis for determining a positive result. The size threshold for positivity depends on the client’s risk factors for tuberculosis.

D. An area of ecchymosis: Bruising at the site is a local skin reaction that can occur after any injection and is unrelated to the diagnostic criteria for a positive Mantoux test.

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Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

Rationale for correct choices:

Insert a large-bore IV catheter: A large-bore IV (18–20 gauge) is necessary to allow rapid administration of blood products and reduce hemolysis of red blood cells during transfusion. This ensures safe and effective delivery of the blood components.
Witness the client signing a consent for transfusion: Informed consent is required before initiating a blood transfusion. The nurse ensures that the client understands the purpose, risks, and potential complications, and witnesses the signing to meet legal and ethical standards.
Have a second nurse confirm the information on the blood lab: Verifying the blood type, crossmatch, and client identifiers with a second nurse reduces the risk of transfusion errors and ensures patient safety before starting the transfusion.

Rationale for incorrect choices:

Explain to the client that transfusion reactions are not serious: Transfusion reactions can be serious, including hemolytic reactions, febrile reactions, or allergic responses. The nurse should educate the client on the potential risks and signs of a reaction rather than minimizing them.
Flush the transfusion tubing with dextrose 5% in water: Blood products should only be administered with 0.9% sodium chloride (normal saline). Flushing with dextrose or other solutions can cause hemolysis and compromise the safety of the transfusion.

A. Limit visitors to 30 min per day. B. Place the client in a semi-private room. C. Instruct visitors who are pregnant to remain 3 feet from the client. D. Wear a lead apron when providing care E. Close the door to the client's room

Correct Answer is ["A","D","E"]

Explanation

Rationale:

A. Limit visitors to 30 min per day: Time restrictions help reduce others’ exposure to radiation from the sealed implant. Limiting duration minimizes cumulative exposure for visitors while still allowing social interaction for the client.

B. Place the client in a semi-private room: Clients with internal radiation implants require a private room to protect others from unnecessary radiation exposure. A semi-private room increases the risk of radiation exposure to other patients and is inappropriate.

C. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant visitors should avoid contact with clients receiving internal radiation entirely, as even minimal exposure could harm the fetus. The safest recommendation is to avoid visiting during treatment.

D. Wear a lead apron when providing care: A lead apron shields the nurse from radiation exposure, especially when working close to the client. This is part of the time, distance, and shielding principles for radiation safety.

E. Close the door to the client's room: Keeping the door closed helps contain radiation within the client’s room, reducing exposure to staff and visitors in nearby areas. This is a standard precaution in caring for clients with sealed implants.

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

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