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 A
Explanation
Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) that can cross-react with sulfa and should be avoided in clients with a sulfa allergy. Atorvastatin, prednisone, and digoxin do not contain sulfa and are safe for clients with a sulfa allergy.
Choice B: Atorvastatin does not contain sulfa and is safe for clients with a sulfa allergy.
Choice C: Prednisone does not contain sulfa and is safe for clients with a sulfa allergy.
Choice D: Digoxin does not contain sulfa and is safe for clients with a sulfa allergy.
Correct Answer is B
No explanation
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