Which nursing assessment indicates a positive reading of a tuberculin (TB) skin test?

1 day after injection with a 10-mm area of redness and swelling

2 days after injection with a 5-mm area of redness and swelling

4 days after injection with a 3-mm area of redness and swelling

5 days after injection with a 2-mm area of redness and swelling

Answer and Explanation

The Correct Answer is A

A. 1 day after injection with a 10-mm area of redness and swelling:

This may suggest a positive reading, but induration size is the primary criterion for interpretation, not just redness and swelling.

B. 2 days after injection with a 5-mm area of redness and swelling:

Similar to option A, a 5-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. Again, without information on the size of the induration, we cannot determine if this reading is positive.

C. 4 days after injection with a 3-mm area of redness and swelling:

Once more, a 3-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. As with the previous options, the size of the induration is the critical factor for interpretation.

D. 5 days after injection with a 2-mm area of redness and swelling:

As with the other options, a 2-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. The presence and size of induration are essential for accurate interpretation.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Start slowly and increase volume over several sessions.

This is the correct choice. For clients having difficulty using an incentive spirometer, starting slowly and gradually increasing the volume over several sessions is an appropriate approach. It allows the client to become familiar with the device and the technique required for effective use. Starting slowly also reduces the risk of discomfort or respiratory distress, allowing the client to build up their lung capacity gradually and achieve optimal results over time.

B. Do regular deep-breathing exercises instead.

Regular deep-breathing exercises are beneficial for improving lung function and respiratory strength. However, using an incentive spirometer serves a specific purpose in promoting deep breathing and lung expansion to prevent atelectasis (lung collapse) and improve respiratory function. While deep-breathing exercises are helpful, they may not provide the same targeted benefits as using an incentive spirometer, especially for clients who are experiencing difficulty with deep breathing or lung expansion.

C. Use another device because this one might be faulty.

This option assumes that the difficulty with the incentive spirometer is due to a fault in the device itself, which may not necessarily be the case. Before considering another device, it's important to ensure that the client is using the current device correctly and receiving proper instruction. If the client continues to have difficulty despite proper technique and instruction, then further assessment of the device may be warranted.

D. Be much more vigorous in increasing increments.

Being much more vigorous in increasing increments is not recommended, as it could lead to discomfort, respiratory distress, or hyperventilation for the client. Increasing the volume too quickly may overwhelm the client and make it more difficult for them to use the incentive spirometer effectively. Gradual progression allows the client to adjust to the device and build up their lung capacity safely and effectively over time.

A. Liver function tests B. Gallbladder studies C. Thyroid function studies D. Blood glucose levels

Correct Answer is A

Explanation

A. Liver function tests

This is the correct choice. Pyrazinamide, a medication used in the treatment of tuberculosis, is known to potentially cause hepatotoxicity, which refers to liver damage or dysfunction. Therefore, clients prescribed pyrazinamide should undergo regular monitoring of liver function tests to assess for any signs of liver injury or impairment. Liver function tests typically include measurements of various enzymes and proteins produced by the liver, such as alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and bilirubin levels.

B. Gallbladder studies

Gallbladder studies are not typically indicated for clients taking pyrazinamide. While pyrazinamide can rarely cause hepatotoxicity, which may affect liver function, it is not known to specifically target or affect the gallbladder. Therefore, routine gallbladder studies are not necessary for clients taking pyrazinamide.

C. Thyroid function studies

Pyrazinamide is not known to directly affect thyroid function. Therefore, routine thyroid function studies are not indicated for clients taking pyrazinamide unless there are specific signs or symptoms suggesting thyroid dysfunction.

D. Blood glucose levels

Pyrazinamide is not known to directly affect blood glucose levels. Therefore, routine monitoring of blood glucose levels is not indicated for clients taking pyrazinamide unless there are specific reasons to suspect or monitor for diabetes mellitus or other conditions affecting blood glucose regulation.

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Which nursing assessment indicates a positive reading of a tuberculin (TB) skin test?

Nursing Test Bank

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