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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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Positioning the knees higher than the hips could increase the risk of hip dislocation.

B. Keeping an abduction pillow between the legs helps maintain the hip in the correct position and prevents dislocation.

C. Raising the head of the bed to a high-Fowler’s position may strain the hip and is not recommended for dislocation prevention.

D. Elevating the affected leg on a pillow may cause internal rotation and increase the risk of dislocation.

A. A client who has a fracture and is in balance suspension traction. B. A client who is bedridden and wears a hearing aid. C. A client who is ambulatory and receiving oxygen. D. A client who uses a wheelchair and is confused.

Correct Answer is C

Explanation

A. A client in balance suspension traction requires more time and assistance, making them a lower priority.

B. A bedridden client requires significant help and is less mobile, lowering their priority.

C. A client who is ambulatory and receiving oxygen is at risk of immediate danger if the oxygen supply poses a fire hazard. They can be evacuated quickly and independently.

D. A client in a wheelchair and confused may require more time and resources for evacuation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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