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Difficulty: MediumHealth Screening

A public health nurse is conducting an annual tuberculosis screening clinic. Arrange the steps the nurse should follow to properly administer and interpret a Mantoux tuberculin skin test (TST) in the correct chronological sequence.

  1. 1Assess the client's history for a previous positive tuberculin skin test or severe reaction.
  2. 2Select and cleanse a localized area on the volar surface of the forearm.
  3. 3Inject 0.10.1 mL of the purified protein derivative (PPD) solution intradermally to produce a pale wheal.
  4. 4Instruct the client to leave the injection site uncovered and avoid scratching the area.
  5. 5Palpate the site 4848 to 7272 hours later and measure the diameter of induration.

Answer

The correct sequence is: assess for a previous positive reaction, prepare the volar forearm, inject the PPD intradermally, educate the client on site care, and measure induration after 4848 to 7272 hours.
The correct sequence reflects the standard nursing process for health screening tests: first ensuring safety by assessing for contraindications (previous positive results), then preparing the anatomical site, administering the test using the correct intradermal technique, providing immediate client education to protect the site from irritation, and finally performing the delayed reading by palpating and measuring the induration.

Step-by-Step Solution

1
Determine if there are contraindications to the screening test.
Assess the client's history for a previous positive TST or severe reaction.
Administering PPD to a client with a known prior positive result can cause a severe localized or systemic hypersensitivity reaction.
2
Prepare the injection site.
Select and cleanse a localized area on the volar surface of the forearm.
Proper site selection (free of veins or lesions) and cleansing with alcohol prevent infection and allow clear visualization.
3
Administer the screening test.
Inject 0.10.1 mL of the PPD solution intradermally to produce a pale wheal.
The PPD must be placed within the dermis (intradermally) to elicit the correct localized cell-mediated immune response.
4
Provide post-procedure client education.
Instruct the client to leave the site uncovered and avoid scratching.
Scratching or covering the site with an adhesive bandage can cause mechanical irritation, mimicking a positive immune response.
5
Interpret the screening results.
Palpate the site 4848 to 7272 hours later and measure the diameter of induration.
The delayed hypersensitivity reaction takes 4848 to 7272 hours to peak. Only the indurated (hard, raised) area is measured in millimeters, not the surrounding erythema.

Key Concept

Tuberculin Skin Test (Mantoux) Administration and Interpretation Sequence
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Topics

Health Screening

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