Practice Question
The nurse is preparing to perform a tuberculin skin test using purified protein derivative (PPD). Which of the following interventions would be important for the nurse to include in the plan of care? (Select all that apply.)
Answer Choices:
Correct Answer:
Inform the client to return for an evaluation of redness 24-36 hours after
Rationale:
Inform the client to return for an evaluation of redness 24-36 hours after
✍️ Tuberculin skin tests (TST) require the client to return 24-72 hours after administration to assess for reaction.
✍️ Redness and induration (raised area) will be evaluated to determine if the client has been exposed to tuberculosis.
✍️ No evaluation should be made too soon, as it may not show a clear reaction in the early stages.
Ask the client about a history of receiving the Bacille Calmette-Guerin vaccine
◈ The BCG vaccine (used in countries with high tuberculosis rates) can cause a false positive on the tuberculin skin test.
◈ Understanding the client's vaccination history helps the nurse interpret test results accurately and differentiate between a true positive and a vaccine response.
◈ If the client received the BCG vaccine, further testing may be necessary to confirm the diagnosis.
Instruct the client that they will need to return in 48-72 hours
🍃 Tuberculin skin test evaluation should be performed 48-72 hours after administration to ensure proper measurement of redness or induration.
🍃 The reaction can be measured at this time for accurate results regarding exposure to tuberculosis.
🍃 Less than 48 hours will not provide accurate test results, as the reaction may still be developing.
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This question is from RN ATI Medsurg Quiz which contains 20 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 5