A nurse is assisting with care for a client who received a tuberculin skin test 72 hr ago. When collecting data from the test site, which of the following findings indicates a need for further testing?
Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter
Area of ecchymosis, greater than 12 mm (0.5 in) in diameter
Tenderness at the injection site
Palpable area of induration, greater than 10 mm (0.4 in) in diameter
The Correct Answer is D
Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease.
The other choices are not correct because:
- Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.
- Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.
- Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should recommend the pneumococcal vaccine to the client, as this is recommended for all adults over the age of 65 to prevent pneumococcal disease. Choice A is incorrect because the tuberculosis vaccine is not routinely given to adults in the United States. Choice B is incorrect because the HPV vaccine is recommended primarily for young adults to prevent HPV-related cancers. Choice C is incorrect because the MMR vaccine is recommended for children, and most adults have already received it. Choice A is not correct because the tuberculosis vaccine is not routinely given to adults in the United States.
Correct Answer is B
Explanation
BUN 40 mg/dL. Elevated BUN levels can indicate impaired kidney function, which can be a potential adverse effect of long-term NSAID therapy.
Reasons why the other options are not answers:
Option A: Total bilirubin 0.8 mg/dL is a normal value and does not require reporting to the provider.
Option C: PaO2 90 mm Hg is within the normal range and does not require reporting to the provider.
Option D: Hematocrit 45% is within the normal range and does not require reporting to the provider.
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