A nurse is planning to administer a tuberculin skin test to a client who has had an exposure to tuberculosis. Which of the following actions should the nurse plan to take?
Select an injection site that is free of scar tissue.
Massage the site following the injection.
Hold the needle at a 30 angle during injection
Inject 0.3 to 0.5 mL of the solution.
The Correct Answer is A
A. When administering a TST, the nurse should select an injection site that is free of scar tissue and areas with excessive hair, veins, or visible lesions. The preferred site for TST administration is the volar aspect of the forearm, approximately 2-4 inches below the elbow.
B. After administering the TST, the nurse should not massage or manipulate the injection site. Massaging the site can cause irritation or spread the solution, leading to inaccurate results.
C. he TST is administered intradermally, typically with a 27-gauge needle. The needle should be inserted with the bevel facing upward at a 5-15-degree angle.
D. The standard dose of tuberculin solution (e.g., purified protein derivative, PPD) for a TST is 0.1 mL containing 5 tuberculin units (TU).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2.3"]
Explanation
1 lb = 0.453592 kg (conversion factor)
Weight in kilograms = 152 lb × 0.453592 kg/lb ≈ 68.946 kg
Calculate the total dosage based on the client's weight:
Total dosage = 5 mg/kg × 68.946 kg
≈ 344.73mg
Determine the volume of enoxaparin solution needed based on the concentration provided: Available concentration: 120 mg/0.8 mL
Dosage required: 344.73mg Using the formula:
Volume (mL) = Dosage required (mg) / Concentration (mg/mL)
= 344.73mg / 120 mg/0.8 mL
= 2.3ml
Correct Answer is D
Explanation
D. Dizziness and lightheadedness may be indicative of hypotension, which can occur as a side effect of ramipril, particularly with the first dose or with dose adjustments. Administering an IV fluid bolus can help increase intravascular volume, improve blood pressure, and alleviate symptoms of hypotension.
A. Administering carbohydrates is not indicated for dizziness and lightheadedness associated with ramipril administration. Carbohydrates are typically used to treat hypoglycemia in clients with diabetes. Dizziness and lightheadedness in this scenario are unlikely to be caused by hypoglycemia.
B. Diphenhydramine is an antihistamine commonly used to treat allergic reactions, itching, and insomnia. It is not indicated for dizziness and lightheadedness associated with ramipril administration. Administering diphenhydramine may not address the underlying cause of the symptoms.
C. Naloxone is a medication used to reverse opioid overdose by blocking the effects of opioids at receptor sites. It is not indicated for dizziness and lightheadedness associated with ramipril administration. Naloxone would not be appropriate in this situation.
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