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

A. Air moves in and out of a wound in the chest wall.

In an open pneumothorax, also known as a sucking chest wound, there is a communication between the pleural space and the external environment through a wound in the chest wall. This allows air to move freely in and out of the pleural cavity during respiration. As a result, there is a loss of negative pressure within the pleural space, impairing lung expansion and leading to respiratory compromise. This condition is considered a medical emergency and requires prompt intervention to prevent tension pneumothorax and respiratory failure.

B. Air cannot pass freely into the thoracic cavity through a chest wound.

In an open pneumothorax, air can pass freely into the thoracic cavity through the chest wound. This communication between the external environment and the pleural space results in air movement in and out of the wound during respiration.

C. There are no audible sounds in an open pneumothorax.

In an open pneumothorax, there may be audible sounds, such as sucking or hissing sounds, particularly during inspiration. These sounds occur due to the movement of air in and out of the chest wound and can be indicative of the condition.

D. The air is trapped when it enters the cavity.

In an open pneumothorax, the air is not trapped when it enters the pleural cavity. Instead, air moves freely in and out of the wound in the chest wall, leading to respiratory compromise and potential progression to tension pneumothorax if left untreated.

A. Assign health care personnel to nondirect care activities for 24 hr after developing influenza symptoms.

While it's important for healthcare personnel to stay home when they have influenza symptoms to prevent transmission to residents and coworkers, restricting them to nondirect care activities for only 24 hours may not be sufficient. Healthcare personnel with influenza symptoms should follow institutional policies regarding sick leave and clearance to return to work, which typically involve staying home until they are no longer contagious.

B. Place restrictions on visitation.

During an influenza outbreak in a long-term care facility, it's crucial to include interventions to prevent further spread of the virus. Placing restrictions on visitation helps reduce the risk of introducing the virus from outside sources into the facility. Visitors may inadvertently bring the influenza virus with them, potentially exposing vulnerable residents and staff members.

C. Implement airborne precautions for clients who have influenza.

Influenza is primarily transmitted through respiratory droplets rather than through airborne transmission. Airborne precautions are not typically necessary for managing influenza in a long-term care facility. Standard precautions, including hand hygiene, respiratory hygiene/cough etiquette, and use of personal protective equipment, are sufficient for preventing transmission.

D. Provide prophylactic antibiotics for clients who have been exposed to influenza.

Influenza is a viral infection and is not treated with antibiotics. Prophylactic antibiotics are not indicated for preventing influenza. Antiviral medications may be used for prophylaxis in certain high-risk individuals or in outbreak settings, but their use should be based on recommendations from public health authorities and healthcare providers, not blanket administration to all exposed individuals.