How do you determine whether a Mantoux test result is positive or negative?
What will be an ideal response?
• You measure the area of induration (not erythema), which is defined as a hardened area under the
skin. The area is measured transverse to the long axis of the forearm.
• The CDC has the following guidelines for a positive Mantoux reaction:
• A PPD induration greater than 5 mm is considered positive for persons with, or at risk for, HIV
infection; those who have had close, recent contact with someone who has infectious TB;
persons who have a chest x-ray (CXR) study that shows old, healed TB; and patients with organ
transplants and people who are immunosuppressed for other reasons.
• A PPD induration greater than 10 mm is considered positive for foreign-born persons from
high-prevalence countries; IV drug users; individuals from medically underserved, lowincome
populations; residents of long-term care facilities; people with chronic illnesses;
mycobacteriology laboratory personnel; and all children and adolescents.
• A PPD induration greater than 15 mm is considered positive for all other persons.
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a. Disseminated intravascular coagulation. b. von Willebrand disease. c. Thrombophlebitis. d. Coagulopathies.
The nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?
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A postoperative child is prescribed morphine sulfate IV for pain. The recommended dose of morphine sulfate is 0.1 mg- 0.2 mg/kg/dose. What is the safe dose for this child who weighs 18 pounds?
a. 0.1 mg to 0.2 mg c. 0.8 mg to 1.6 mg b. 1.6 mg to 3.2 mg d. 0.8 mg/kg to 1.6 mg/kg
The nurse is performing an assessment on a 2-hour-old newborn. Which finding would warrant a call to the health care provider?
a. A crepitant-like feeling when assessing the clavicles b. Blood glucose of 45 mg/dL when using a Dextrostix c. Heart rate of 160 beats/minute after vigorous crying d. Passage of a dark green substance from the intestine