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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Use an elevated toilet seat: Using an elevated toilet seat can help prevent excessive bending of the hip joint, reducing strain and potential dislocation risk after total hip replacement surgery.
B. Log rolling onto the operative side is contraindicated after total hip replacement surgery. This movement could place excessive stress on the newly replaced hip joint, increasing the risk of dislocation and complications.
C. Keeping the affected heel on the bed helps maintain proper alignment and precautions after total hip replacement surgery. It supports the hip joint and reduces the risk of dislocation by preventing excessive rotation or movement.
D. While some hip exercises are beneficial, internal and external rotation exercises are typically avoided immediately after total hip replacement surgery to prevent strain on the new joint.

A. Move the client up and down in bed by holding onto the halo traction device. B. Ensure that there is space for one finger to fit between the vest and the client's skin. C. Apply medicated powder under the vest to reduce itching. D. Loosen or tighten the screws on the device as needed for the client's comfort.

Correct Answer is B

Explanation

B. Ensuring that there is space for one finger to fit between the vest and the client's skin helps prevent skin breakdown and pressure injuries. The halo vest should fit snugly but not too tight to allow for proper circulation and comfort.
A. Moving the client by holding onto the halo traction device can disrupt the device's stability and potentially cause harm to the client.
C. Applying medicated powder under the vest can introduce foreign substances to the skin and may increase the risk of skin irritation or infection.
D. This should only be performed under the guidance of a healthcare provider.

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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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