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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Correct Answer is D

Explanation

Answer is: d. Reposition the client.

Explanation: Repositioning the client can help alleviate pain by redistributing pressure and promoting comfort. Since the client's pain level is relatively low (2 on a scale of 0 to 10), this non-pharmacological intervention is an appropriate initial action.

Choice a. is wrong because maintaining the client on bed rest is not an appropriate action for a pain level of 2. Instead, the nurse should encourage the client to mobilize and perform appropriate exercises to prevent complications related to immobility.

Choice b. is wrong because applying a warm, moist compress to the incision area might not be the best action for a client who is 24 hours postoperative, as it could increase the risk of infection and cause discomfort. Cold compresses are often used in the initial postoperative period to reduce swelling and promote comfort.

Choice c. is wrong because administering an additional dose of pain medication is not necessary at this point, as the client's pain level is relatively low. The nurse should consider non-pharmacological interventions first and reassess the client's pain level to determine the need for further pain relief.

A. Place the client in the Trendelenburg position B. Encourage active range of motion exercises of the right arm C. Keep the client's right arm immobilized D. Instruct the client to cough frequently

Correct Answer is C

Explanation

The client's right arm should be immobilized to prevent dislodgment of the central venous catheter. The Trendelenburg position is not indicated in this situation and may increase the risk of complications. Active range of motion exercises of the right arm and frequent coughing can also increase the risk of catheter dislodgment.

Choice A, placing the client in the Trendelenburg position, is not the correct answer because it is not indicated in this situation and may increase the risk of complications.

Choice B, encouraging active range of motion exercises of the right arm, is not the correct answer because it can increase the risk of catheter dislodgment.

Choice D, instructing the client to cough frequently, is not the correct answer because it can increase the risk of catheter dislodgment.

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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

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