which techniques should the nurse use to administer an intradermal id injection for a mantoux test to screen for tuberculosis tb select all that apply
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Nursing Elites

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HESI CAT Exam

1. Which techniques should be used to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB)? Select all that apply.

Correct answer: A

Rationale: Observing for an intradermal bleed after the antigen is injected is a proper technique for an ID injection. This is important to confirm the correct placement of the injection. Choice B is correct because the recommended site for an ID injection for a Mantoux test is the volar surface of the forearm. Choice C is incorrect because the standard needle size for an ID injection is usually 26 or 27 gauge with a length of 1/4 to 5/8 inches, not 25 gauge with a length of 1/2 inch. Choice D is incorrect because the needle should be inserted into the skin with the bevel facing up, not down.

2. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned, and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?

Correct answer: B

Rationale: In the scenario described, the nurse notes late decelerations during contractions despite repositioning and oxygen administration. Late decelerations are often associated with uteroplacental insufficiency, which can be exacerbated by increased uterine activity stimulated by oxytocin. The initial action to manage late decelerations is to turn off the oxytocin infusion to reduce uterine stimulation. This step aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth may be necessary if the late decelerations persist or worsen despite discontinuing the oxytocin infusion. Notifying the anesthesiologist to disconnect the epidural infusion or applying an internal fetal monitoring device are not the first-line interventions for managing late decelerations.

3. The unlicensed assistive personnel (UAP) has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take?

Correct answer: D

Rationale: Proper application of personal protective equipment (PPE) is crucial to maintain infection control. In this scenario, the nurse should help the UAP reposition the gown sleeve over the gloves' edges. This action ensures that the gown properly covers the gloves, reducing the risk of contamination. Choices A, B, and C are incorrect because the primary concern is to address the improper application of PPE by repositioning the gown sleeves over the gloves, not checking other aspects of PPE or reminding about hand hygiene.

4. When designing a plan of care for a client diagnosed with pheochromocytoma, a goal statement should be prepared that relates to which topic?

Correct answer: C

Rationale: The correct answer is C: Preoperative and postoperative teaching for adrenalectomy. Pheochromocytoma often requires adrenalectomy as part of the treatment plan. Therefore, educating the client about what to expect before and after the surgery is crucial for optimal care and outcomes. Choices A, B, and D are incorrect. Choice A focuses on emotional well-being rather than the specific surgical intervention needed for pheochromocytoma. Choice B is unrelated as the primary treatment for pheochromocytoma is surgical rather than medication-based. Choice D, though related to managing hypertension, does not address the surgical aspect of treating pheochromocytoma.

5. When deciding whether to join a nursing strike called after collective bargaining efforts have failed, which factor is most important for the nurse to consider?

Correct answer: B

Rationale: The correct answer is B. The role of nurses as client advocates is crucial when considering the impact of a strike on patient care. Nurses have a responsibility to advocate for their patients' well-being at all times. Choices A, C, and D, although important, are not the most critical factor to consider in this situation. The Nurse Practice Act of the State is essential for guiding nursing practice, standards of clinical nursing practice ensure quality care, and personal values are important; however, the primary focus during a strike should be on the role of nurses as client advocates.

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