An employee health nurse is preparing to administer a Mantoux tuberculin skin test (TST) to a newly hired healthcare worker as part of an occupational health screening protocol. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.
- 1Assess the employee's health record for a documented history of a positive tuberculin skin test.
- 2Cleanse a selected site on the volar surface of the forearm with an alcohol swab and let it air dry.
- 3Inject the purified protein derivative (PPD) solution intradermally with the needle bevel facing upward.
- 4Observe the injection site immediately to confirm the formation of a discrete, pale wheal.
- 5Instruct the employee to return to the employee health department in 48 to 72 hours for the test interpretation.
Answer
The correct sequence of steps for administering a tuberculin skin test is to assess for contraindications, prepare the injection site, administer the intradermal injection, verify wheal formation, and instruct the client on follow-up timing.
The sequence reflects the standard nursing process and evidence-based guidelines for administering an intradermal screening test. First, the nurse must perform a targeted assessment to rule out contraindications, such as a history of a positive Mantoux test, which could lead to a severe localized reaction. Once cleared, the nurse prepares the site on the volar forearm using aseptic technique. The administration of the tuberculin solution follows, utilizing a precise 5- to 15-degree angle with the bevel up to ensure intradermal placement. Immediately following the injection, the nurse evaluates the site for the formation of a 6 to 10 mm wheal, which confirms correct technique. Finally, the nurse provides client education regarding the strict 48- to 72-hour timeframe required for an accurate reading of the screening results.
Step-by-Step Solution
Key Concept
Tuberculosis Screening and Intradermal Injection Protocol