A nurse is assisting with care for a client who received a tuberculin skin test 72 hr ago. When collecting data from the test site, which of the following findings indicates a need for further testing?

Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter

Area of ecchymosis, greater than 12 mm (0.5 in) in diameter

Tenderness at the injection site

Palpable area of induration, greater than 10 mm (0.4 in) in diameter

Answer and Explanation

The Correct Answer is D

Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease.

The other choices are not correct because:

- Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.

- Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.

- Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is {"xRanges":[124.765625,154.765625],"yRanges":[96.609375,126.609375]}

Explanation

{"A":{"choice":"-","reason":"

is not the correct answer because the tricuspid area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The tricuspid area is located at the fifth intercostal space at the lower left sternal border, and is the site where blood flows from the right atrium to the right ventricle during systole.<\/p>"},"B":{"choice":"-","reason":"

The correct answer is choice B, the mitral area. When auscultating for a murmur in a client with mitral valve regurgitation, the nurse should place the stethoscope at the mitral area, which is the fifth intercostal space at the left midclavicular line. This is because the mitral valve is located at this spot and is the site where blood flows from the left atrium to the left ventricle during systole.<\/p>"},"C":{"choice":"-","reason":"

is not the correct answer because the aortic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The aortic area is found at the second intercostal space at the right sternal border, and is the site where blood flows from the left ventricle to the aorta during systole.
\r\nChoiceD4 is not the correct answer because the pulmonic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The pulmonic area is located at the second intercostal space at the
\r\n
\r\nleft sternal border, and is the site where blood flows from the right ventricle to the pulmonary artery during systole.<\/p>"},"D":{"choice":"-","reason":"

A. Brain natriuretic peptide 275 pg/mL B. Calcium 9.0 mg/dL C. Sodium 140 mEq/L D. Potassium 4.0 mEq/L

Correct Answer is A

No explanation

View Question and Answer

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A nurse is assisting with care for a client who received a tuberculin skin test 72 hr ago. When collecting data from the test site, which of the following findings indicates a need for further testing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has mitral valve regurgitation. In which of the following areas should the nurse place the stethoscope to auscultate a murmur? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is {"xRanges":[124.765625,154.765625],"yRanges":[96.609375,126.609375]}

Explanation

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