Practice Quiz

ANCC Medical-Surgical Nursing Exam Prep

Category - Pulmonary

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A nurse is reading the results of a TB skin test on Ms. Dressler, a 72-year-old resident in a Nursing Home. Ms. Dressler has never had a TB skin test. There is no induration around the injection site. The nurse should document the test as negative and:
  1. State that the client does not have TB
  2. Have the client repeat the skin test in 2 weeks
  3. Schedule the client repeat for a follow-up chest X-ray
  4. Start the client on prophylactic TB medications because the client is in a high-risk group
Explanation
Answer - B - The client who is elderly may test as false negative because of diminished hypersensitivity-type immune response. It is best to do the 2-step TB skin test and have client repeat the test 1-3 weeks after the first test. If the second skin test is still negative, then the client can be informed that she does not have TB. If the second test is positive, then the client should receive a follow up chest X-ray and prophylactic treatment.
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