Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with care for a client who received a tuberculin skin test 72 hr ago. When collecting data from the test site, which of the following findings indicates a need for further testing?
A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter
Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.
B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter
Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.
C. Tenderness at the injection site
Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.
D. Palpable area of induration, greater than 10 mm (0.4 in) in diameter
Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease. The other choices are not correct because:
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease.
The other choices are not correct because:
- Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.
- Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.
- Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.
Similar Questions
A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following assessment findings should the nurse report to the provider?
A. Report of shoulder pain
Choice A, reporting of shoulder pain, is not the correct answer because this is a common finding post-cholecystectomy, which is often due to the presence of carbon dioxide used during the surgical procedure.
B. Thick, green-brown drainage on dressing
This finding could indicate the presence of bile leakage, which can occur following a cholecystectomy. The provider should be notified immediately as the client may require further interventions. Incisional pain, shoulder pain, and a dry and intact abdominal dressing are expected findings in the postoperative period.
C. Incisional pain 5 out of 10 on a pain scale
Choice C, incisional pain 5 out of 10 on a pain scale, is not the correct answer because this level of pain is within the expected range for the postoperative period.
D. Abdominal dressing dry and intact
Choice D, abdominal dressing dry and intact, is not the correct answer because this is an expected finding in the postoperative period.
Full Explanation
This finding could indicate the presence of bile leakage, which can occur following a cholecystectomy. The provider should be notified immediately as the client may require further interventions. Incisional pain, shoulder pain, and a dry and intact abdominal dressing are expected findings in the postoperative period.
Choice C, incisional pain 5 out of 10 on a pain scale, is not the correct answer because this level of pain is within the expected range for the postoperative period.
Choice D, abdominal dressing dry and intact, is not the correct answer because this is an expected finding in the postoperative period.
A nurse is caring for a client who has just had a central venous catheter placed via the right subclavian vein. Which of the following actions should the nurse take?
A. Place the client in the Trendelenburg position
Choice A, placing the client in the Trendelenburg position, is not the correct answer because it is not indicated in this situation and may increase the risk of complications.
B. Encourage active range of motion exercises of the right arm
Choice B, encouraging active range of motion exercises of the right arm, is not the correct answer because it can increase the risk of catheter dislodgment.
C. Keep the client's right arm immobilized
The client's right arm should be immobilized to prevent dislodgment of the central venous catheter. The Trendelenburg position is not indicated in this situation and may increase the risk of complications. Active range of motion exercises of the right arm and frequent coughing can also increase the risk of catheter dislodgment.
D. Instruct the client to cough frequently
Choice D, instructing the client to cough frequently, is not the correct answer because it can increase the risk of catheter dislodgment.
Full Explanation
The client's right arm should be immobilized to prevent dislodgment of the central venous catheter. The Trendelenburg position is not indicated in this situation and may increase the risk of complications. Active range of motion exercises of the right arm and frequent coughing can also increase the risk of catheter dislodgment.
Choice A, placing the client in the Trendelenburg position, is not the correct answer because it is not indicated in this situation and may increase the risk of complications.
Choice B, encouraging active range of motion exercises of the right arm, is not the correct answer because it can increase the risk of catheter dislodgment.
Choice D, instructing the client to cough frequently, is not the correct answer because it can increase the risk of catheter dislodgment.
A nurse is assisting with discharge teaching for a client who requires oropharyngeal suctioning at home. The nurse should ensure that which of the following equipment is available for use at home?
A. Oropharyngeal airway
This is incorrect because an Oropharyngeal airway is used to maintain or open the airway.
B. Water-soluble lubricant
This is incorrect because water-soluble lubricant is used for lubricating the suction catheter during suctioning.
C. Yankauer catheter
A Yankauer catheter is a suction device used for oral suctioning. It is important for this client to have access to a Yankauer catheter for safe and effective suctioning of secretions from the mouth.
D. Sterile gloves
This is incorrect because sterile gloves are not routinely needed for suctioning.
E. Sterile gloves
Full Explanation
Yankauer catheter. A Yankauer catheter is a suction device used for oral suctioning. It is important for this client to have access to a Yankauer catheter for safe and effective suctioning of secretions from the mouth.
Option A is incorrect because an Oropharyngeal airway is used to maintain or open the airway.
Option B is incorrect because the water-soluble lubricant is used for lubricating the suction catheter during suctioning.
Option D is incorrect because sterile gloves are not routinely needed for suctioning.
Reasons why the other options are not answered: Option A: An oropharyngeal airway is not used for suctioning but is used to maintain an open airway in an unconscious patient. Option B: Water-soluble lubricant is used for lubricating the suction catheter during suctioning. Option D: Sterile gloves are not routinely needed for suctioning.