A patient received a tuberculosis skin test injection of purified protein derivative (PPD) 72 hours ago. Which assessment finding of the test site does the nurse interpret as a positive reaction?
a. The injected area has a blister-like swelling about 2 mm high and 2 mm in di-ameter.
b. The injection site is puffy and soft with pus oozing from the needle hole.
c. The skin is red and very hard for 12 mm around the injection site.
d. There is a large bruise surrounding the injection site.
C
A positive reaction to a TB skin test requires that the skin around the injection site be indurated, not just red. Induration is caused by infiltration of the skin around the test site with many white blood cells, making the area red and swollen, and the tissue much harder than the surrounding normal skin. Bruising is a result of bleeding into the injection site, not infiltration and induration from white blood cells.
You might also like to view...
Tuberculosis
A) can be spread by persons who have positive skin tests and no symptoms. B) presents a higher risk for clients who take immunosuppressant medications. C) is caused by a virus related to human immunodeficiency virus (HIV). D) in the early stage, causes the client to gain weight and be short of breath.
A nurse who has a history of difficulty meeting the professional responsibilities of acute care nursing is considering a move to ambulatory nursing
What should this nurse consider about the professional responsibilities of ambulatory nursing prior to making this decision? 1. Ambulatory nursing is totally different from acute care nursing. 2. The responsibilities are equally as technical and demanding as those of acute care nursing. 3. The duty to communicate is lessened in ambulatory care nursing. 4. Ambulatory nursing is less physically demanding on the nurse.
A client with hypercholesterolemia and atherosclerosis is prescribed nicotinic acid (Niaspan). Which instruction does the nurse provide the client?
a. "This medication may make you flush." b. "Take this medication on an empty stomach." c. "You will not need to change your diet with this medication." d. "Take this medication when you experience chest pain."
Ketones are produced when insufficient _____ is available and the body has to metabolize _____ for energy
a. carbohydrate; fat b. fat; carbohydrate c. carbohydrate; protein d. protein; carbohydrate