The nurse will record a positive reading of a tuberculin skin test when it is assessed:
1. 1 day postinjection with a 10-mm area of redness and swelling.
2. 2 days postinjection with an 8-mm area of redness and swelling.
3. 4 days postinjection with a 3-mm area of redness and swelling.
4. 5 days postinjection with a 2-mm area of redness and swelling.
2
A positive reading of a TB skin test is an area of redness and swelling of 5 mm or larger 24 to 48 hours postinjection.
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When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an epidural for delivery. What is a contraindication to an epidural block?
a. Abnormal clotting b. Previous cesarean delivery c. History of migraine headaches d. History of diabetes mellitus
The nurse is alarmed as she assesses a protruding umbilical cord from the vagina. What immediate action should the nurse take?
a. Monitor intensity of contractions b. Place the patient in the knee-chest position c. Notify the charge nurse d. Ask the patient to perform a Valsalva maneuver
The nurse is explaining the use of antiembolism hose and instructing the client in leg exercises. Both of these interventions will prevent the postoperative complication of:
a. atelectasis. b. shock. c. thrombophlebitis. d. pain.
The nurse assesses the glossopharyngeal nerve (CN IX) by testing which reflex?
a. Corneal reflex b. Gag reflex c. Blink reflex d. Cough reflex