Editing Nursing Skills and Procedures – RN Practice Questions (section)

==Question 5==
A registered nurse reads a tuberculin skin test 72 hours after placement on a client who is receiving long-term corticosteroid therapy. The nurse palpates an area of induration measuring 7 mm surrounded by 15 mm of erythema. How should the nurse interpret this result?
# Negative, because the induration is less than 10 mm.
# Negative, because erythema is not measured.
# Positive, because 5 mm or more of induration is significant in an immunosuppressed client.
# Positive, because the total reaction including erythema exceeds 15 mm.

'''Answer:''' 3 (C). Positive, because 5 mm or more of induration is significant in an immunosuppressed client.

''Rationale:'' Only induration is measured, and the significance threshold depends on risk. Five millimeters is positive for immunosuppressed clients, including those on chronic corticosteroids, clients with human immunodeficiency virus, transplant recipients, and recent close contacts of active cases. Ten millimeters applies to other higher-risk groups and 15 mm to those with no risk factors. Options 1 and 2 apply the wrong threshold or the wrong conclusion, and option 4 incorrectly includes erythema. A positive result reflects exposure and requires follow-up chest imaging and symptom assessment, not an immediate diagnosis of active disease.