A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?
A reddened area measuring 10 mm
A reddened area measuring 5 mm
An induration measuring 5 mm
An induration measuring 10 mm
The Correct Answer is D
A. A reddened area without induration is not a positive result.
B. A reddened area without induration is not considered positive.
C. An induration of 5 mm is positive only for high-risk groups (e.g., immunocompromised clients).
D. An induration measuring 10 mm is considered positive in most adults, indicating TB exposure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","F"]
Explanation
A. Exert upward pressure on the presenting part. If there are signs of cord prolapse or pressure on the umbilical cord, exerting upward pressure on the presenting part can relieve compression. This action helps maintain blood flow and oxygen supply to the fetus.
B. Place the client in a Trendelenburg position. Positioning the client with the pelvis elevated higher than the head can reduce pressure on the umbilical cord if prolapse is suspected or confirmed. This promotes fetal circulation and decreases the risk of hypoxia.
C. Administer oxygen at 10 L/min via nonrebreather face mask. Administering high-flow oxygen increases maternal oxygenation, which in turn improves oxygen delivery to the fetus. This is a priority intervention to ensure fetal well-being during labor.
D. Attempt to push the umbilical cord back into the cervix. This is incorrect because pushing the cord back into the cervix is contraindicated due to the risk of damaging the cord or introducing infection. Other measures, such as repositioning and elevating the presenting part, should be prioritized instead.
E. Have the charge nurse notify the provider. Timely communication with the provider is critical when complications arise during labor, such as suspected umbilical cord prolapse. The provider may need to intervene urgently, possibly requiring an emergency cesarean section.
F. Increase the flow rate of the maintenance IV fluid. Increasing the IV fluid rate helps improve maternal circulation and blood flow to the uterus and placenta, ensuring the fetus receives adequate oxygen and nutrients. This is a supportive measure during labor when complications arise.
Correct Answer is D
Explanation
A. A 25-gauge needle is too small and inappropriate for accessing a port.
B. An angiocatheter is used for peripheral IV access, not for implanted ports.
C. A butterfly needle is used for venipuncture, not for accessing ports.
D. A noncoring needle (e.g., Huber needle) is specifically designed to access an implanted venous port without causing damage to the septum, preserving the integrity of the port.
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