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 C

Explanation

The correct answer is choice C. Implement droplet precautions. Streptococcal pharyngitis is a highly contagious infection caused by group A beta-hemolytic streptococcus. Droplet precautions are the appropriate precautionary measures to prevent the spread of the infection. This includes placing the client in a private room or with a client with the same infection, wearing a mask or respirator, and using proper hand hygiene. Option A is incorrect because negative airflow rooms are not required for clients with streptococcal pharyngitis. Option B is incorrect because throat cultures should be obtained before the initial dose of antibiotics. Option D is incorrect because fluid restriction is not a necessary intervention for clients with streptococcal pharyngitis.

Option A - Negative airflow rooms are used for airborne illnesses like tuberculosis.

Option B - Throat culture should be obtained before the initial dose of antibiotics.

Option D - Fluid restriction is not a necessary intervention for clients with streptococcal pharyngitis.

A. Add a weight-bearing exercise regimen. B. Take calcium carbonate supplements once a day with breakfast. C. Limit vitamin D intake. D. Increase daily intake of vitamin E.

Correct Answer is A

Explanation

The correct answer is choice A. Weight-bearing exercise is an important way to decrease the risk of osteoporosis in a postmenopausal client. Choice B is incorrect because calcium carbonate supplements should be taken multiple times throughout the day for better absorption. Choice C is incorrect because vitamin D intake should be increased. Choice D is incorrect because there is no evidence that vitamin E intake decreases the risk of osteoporosis. Choice B is not correct because calcium carbonate supplements should be taken multiple times throughout the day for better absorption. Choice C is not correct because vitamin D intake should be increased.

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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 assisting in developing the plan of care for a client with streptococcal pharyngitis. What is an appropriate action to include in the plan of care?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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