Question

A nurse is reading a client's tuberculin skin test 48 hours after placement and notes an 11-mm area of induration. The client is a recent immigrant from Nigeria and reports no symptoms. Which actions would be appropriate by the nurse?

Answer 1

The nurse should consider the positive 11-mm induration in the context of the client being a high-risk individual and refer them for further medical evaluation, including a chest radiograph, and review their BCG vaccination history.

Step-by-step explanation:

A nurse reading a client's tuberculin skin test 48 hours after placement notes an 11-mm area of induration. The appropriate actions by the nurse would include considering the size of the induration in the context of the individual's risk factors. In this case, since the client is a recent immigrant from Nigeria, a high-risk country for tuberculosis (TB), the induration size suggests a positive reaction, indicating exposure to TB. The nurse should refer the client for further medical evaluation, which may include a chest radiograph to check for active TB disease, and a review of the client's history for any previous BCG vaccination. This vaccine can cause a false-positive tuberculin skin test. It is imperative for the nurse to document the finding, inform the client about the implications, and ensure a prompt follow-up in line with public health guidelines.