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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "You will need to change the IV dressing site once per week.": Central line dressings for TPN are typically changed every 48–72 hours for gauze or every 5–7 days for transparent dressings, or sooner if the dressing becomes damp, loose, or soiled, to reduce infection risk.
B. "You will need to warm the solution in the microwave before administration.": TPN solutions should never be microwaved due to the risk of uneven heating and nutrient degradation. They should be administered at room temperature.
C. "You will need to weigh the client twice per week.": Clients receiving TPN require daily weights to monitor fluid balance, nutritional status, and detect fluid retention or dehydration promptly. Twice-weekly measurements are insufficient for close monitoring.
D. "You will need to monitor the client's electrolytes daily.": TPN can cause rapid changes in fluid and electrolyte balance, so daily electrolyte monitoring allows timely adjustments to prevent complications such as hypo- or hypernatremia, hypokalemia, and metabolic imbalances.
Correct Answer is D
Explanation
A. Raise the side rails up when the client is in bed: Full side rails can increase the risk of entrapment and injury for clients with dementia. They are not recommended as a routine safety measure unless individually assessed and ordered.
B. Place the bedside table at the foot of the bed: Placing furniture at the foot of the bed can create obstacles and increase the risk of trips and falls. The environment should be arranged to allow safe, unobstructed mobility.
C. Keep the television on during the night: Continuous noise, such as a TV, can cause agitation or confusion in clients with dementia, increasing the risk of disorientation and injury. Quiet, calming environments are preferred.
D. Assist the client to the toilet frequently: Clients with dementia are at increased risk for falls due to urgency, confusion, or impaired mobility. Frequent toileting assistance reduces the risk of incontinence-related hazards and falls, promoting safety and dignity.
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