Safe, Effective Care Environment
49. A nurse tells a client that a positive reaction to a tuberculosis (TB) test will be determined by:
Safe, Effective Care Environment
49. A nurse tells a client that a positive reaction to a tuberculosis (TB) test will be determined by:
. The appearance of redness after 24 hours.
. The size of the induration 48 hours after the test.
. The diameter of the reddened area at the site.
. The length of time it takes before redness or induration appears.
Test-Taking Tip
Select the only option that just addresses induration. The other three all include redness.
Content Area: Adult Health, Infectious Disease; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Safety and Infection Control/Standard/Transmission-based/Other Precautions
Safe, Effective Care Environment
.
Answer 1 is incorrect because redness alone is not an indication of a positive test. Also, the reaction is assessed at 48 hours after testing, not after 24 hours. Answer 2 is correct because the presence of a positive TB test is determined by the size of the induration. Induration of 10 mm or more is a positive reaction. Answer 3 is incorrect because redness is not the indicator of a reaction. The diameter of the induration (raised area) is important. Answer 4 is incorrect because the test is not read before 48 hours regardless of when redness or induration appears.