A nurse is assessing a client who received a purified protein derivative (PPD) skin test 48 hr ago and notes erythema with induration of 12 mm at the injection site. Which of the following instructions should the nurse provide to the client?

"You will need to have the skin test annually."

"You will need to follow up with your provider."

"You will need to return in 48 hours for re-evaluation."

"Your test will need to be repeated at this time."

Answer and Explanation

The Correct Answer is B

B. The client's PPD skin test result of 12 mm induration is considered positive for individuals who are at increased risk of tuberculosis, such as those with recent exposure to tuberculosis or immunocompromised individuals. A positive PPD result typically requires follow-up with a healthcare provider for further evaluation, which may include chest X-rays, sputum cultures, and treatment for latent tuberculosis infection if indicated.
A. Annual PPD testing may be indicated for certain populations, such as healthcare workers or individuals at high risk of exposure to tuberculosis. However, the decision to repeat the PPD test annually should be based on individual risk factors and healthcare provider recommendations.
C. The PPD skin test is typically read 48-72 hours after administration to assess for induration.
D. A PPD skin test result of 12 mm induration is considered positive for individuals at increased risk of tuberculosis, but it does not necessarily indicate that the test needs to be repeated immediately.

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Correct Answer is D

Explanation

D. Obtaining an electrocardiogram (ECG) is the first action to take when managing a client with an electrical shock injury. Electrical shock injuries can cause cardiac dysrhythmias, including ventricular fibrillation or other life-threatening arrhythmias. Therefore, obtaining an ECG allows for prompt assessment of cardiac rhythm and identification of any dysrhythmias that may require immediate intervention.
A. While fluid resuscitation may be necessary in the management of electrical shock injuries to address hypovolemia and promote renal perfusion, titrating IV fluids to maintain a specific urine output is not the first action to take.
B. Pain management is important in the care of clients with electrical shock injuries, but it is not the first action to prioritize
C. Changing dressings over the entrance and exit wounds is important for wound care, but it is not the first action to take.

A. Metabolic acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Respiratory acidosis

Correct Answer is C

Explanation

C. Metabolic alkalosis is characterized by an increase in serum bicarbonate levels, resulting in an imbalance in the body's acid-base equilibrium towards alkalinity. Excessive ingestion of antacids, particularly those containing bicarbonate or calcium carbonate, can lead to an excessive accumulation of bicarbonate ions in the body, causing metabolic alkalosis.
A. Excessive ingestion of antacids would not typically cause metabolic acidosis because antacids containing bicarbonate or calcium carbonate actually increase bicarbonate levels, leading to alkalosis rather than acidosis.
B. Respiratory alkalosis occurs due to hyperventilation, leading to a decrease in carbon dioxide levels and subsequent alkalosis. Excessive ingestion of antacids is not typically associated with respiratory alkalosis.

D. Respiratory acidosis occurs due to hypoventilation, leading to an increase in carbon dioxide levels and subsequent acidosis. Excessive ingestion of antacids is not typically associated with respiratory acidosis.

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A nurse is assessing a client who received a purified protein derivative (PPD) skin test 48 hr ago and notes erythema with induration of 12 mm at the injection site. Which of the following instructions should the nurse provide to the client?

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse in an emergency department is caring for a client who is receiving treatment for excessive ingestion of antacids. The nurse should identify that this client is at risk for which of the following acid- base imbalances?

Correct Answer is C

Explanation

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