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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.

Nursing Test Bank

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

Assessment Findings Consistent with Mastitis or Endometritis

Painful, tender breast: Mastitis
- Mastitis often presents with breast pain, tenderness, and redness.
Foul-smelling lochia: Endometritis
- Endometritis can cause foul-smelling vaginal discharge or lochia.
Temperature: Both Mastitis and Endometritis
- Both conditions can cause fever.
Chills: Both Mastitis and Endometritis
- Chills can be a symptom of both mastitis and endometritis

A. Apply a transparent dressing to the wound. B. Tie a tourniquet around the leg distal to the wound. C. Apply direct pressure to the wound with thick dressing material. D. Irrigate the wound with sterile water.

Correct Answer is C

Explanation

A. Apply a transparent dressing to the wound: Incorrect. Transparent dressings are not appropriate for controlling active bleeding.

B. Tie a tourniquet around the leg distal to the wound: Incorrect. A tourniquet should only be used as a last resort if direct pressure fails to control the bleeding.

C. Apply direct pressure to the wound with thick dressing material: Direct pressure is the first-line intervention to control bleeding and promote hemostasis.

D. Irrigate the wound with sterile water: Incorrect. Irrigation is not the priority in an actively bleeding wound; controlling the bleeding is more critical.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not.. I found the title to the car today, signed over to me.
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom. Client reports not wanting to eat anymore. Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

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 4 days postpartum following a cesarean birth. Exhibits For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

A nurse in an emergency department is caring for a client who is actively bleeding from a stab wound to the thigh. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client. Exhibits Select the 2 actions that the nurse should take.

A nurse manager is planning a staff in-service to address advocacy in client care. The nurse should promote which of the following practices during the in- service? (Select all that apply.)

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