Final answer:
When performing a tuberculosis skin test, the nurse should cleanse the site with alcohol and may apply a bandage post-injection. Actions such as pre-administration of antipyretic medication or instructing the client to scratch the site are not part of the protocol. A positive result shows a delayed hypersensitivity reaction and may require additional confirmation tests.
Step-by-step explanation:
Performing a Tuberculosis Skin Test
A nurse preparing to perform a tuberculosis skin test should include specific steps to ensure accuracy and prevent infection. The Mantoux tuberculin skin test involves injecting a purified protein derivative (PPD) of the tuberculin from Mycobacterium tuberculosis into the skin, often on the forearm. Upon administration, a small, pale elevation of the skin, a wheal, should appear to indicate that the test substance was properly injected.
The correct actions the nurse should take include:
Actions not recommended or necessary include administering an antipyretic medication before the test, which is not a standard procedure, and asking the client to scratch the injection site, which can cause irritation or infection and interfere with the reading of the test results.
The test is read 48-72 hours after administration. A positive result is characterized by redness, swelling, or a hard area (induration) at the injection site, indicating a cellular immune response. However, previous vaccination with BCG can cause false-positive results, hence further confirmation with chest radiography may be required.