A nurse is planning care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following interventions should the nurse include?

Choice A reason: A blister-like area is not indicative of a positive Mantoux test, which shows induration; blisters suggest irritation. Assuming blisters are positive risks misdiagnosis, potentially missing tuberculosis exposure, critical to avoid in ensuring accurate screening and follow-up in clients tested for TB.

Choice B reason: Ecchymosis (bruising) is not a positive Mantoux result; induration indicates exposure. Assuming ecchymosis is positive risks incorrect interpretation, potentially overlooking tuberculosis risk, critical to prevent in ensuring proper screening, diagnosis, and follow-up for clients undergoing TB skin testing.

Choice C reason: A cool, blanched area suggests no reaction, not a positive Mantoux test, which requires induration. Assuming blanching is positive risks missing exposure, critical to avoid in ensuring accurate tuberculosis screening, guiding appropriate diagnostic follow-up, and protecting client and public health.

Choice D reason: An elevated, hardened area (induration) at 72 hours indicates a positive Mantoux test, suggesting TB exposure, requiring further evaluation. This is critical for accurate screening, ensuring timely diagnosis, preventing disease spread, and guiding follow-up in clients tested for tuberculosis exposure.

Choice A reason: Bed rest for 24 hours post-surgery increases stasis, risking thrombosis; range-of-motion exercises promote circulation. Assuming bed rest is correct risks complications, critical to avoid in ensuring active circulation and preventing venous thromboembolism in postoperative clients during recovery.

Choice B reason: Placing a pillow under knees promotes venous pooling, increasing clot risk; range-of-motion exercises are safer. Assuming pillow use is correct risks impaired circulation, critical to prevent in ensuring effective postoperative care and reducing thrombosis risk in surgical clients.

Choice C reason: Incentive spirometry prevents respiratory complications, not directly promoting circulation; range-of-motion exercises are key. Assuming spirometry aids circulation risks overlooking mobility needs, critical to avoid in ensuring proper venous return and clot prevention in postoperative clients during recovery.

Choice D reason: Range-of-motion exercises promote circulation post-surgery, preventing venous stasis and thrombosis, critical for recovery. This instruction ensures active blood flow, essential for reducing clot risk, supporting healing, and enhancing postoperative outcomes in clients across various surgical procedures.