The nurse assesses the site where a client received an intradermal purified protein derivative (ie, Mantoux) test 48 hours ago and notices a 16-mm area of induration. The client has no symptoms. Which action will the nurse take next?

Question

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The intradermal purified protein derivative (PPD) test, or Mantoux test, is administered to screen for tuberculosis (TB). The forearm is injected with 0.1 mL of the PPD, and the client returns in 48-72 hours to have the site assessed for induration (a raised area). Redness alone is not read as a positive response. An area of induration >15 mm is considered a positive response in any client (Option A). However, a positive PPD test does not mean that the client has active TB infection but rather that the client has been exposed to TB and has developed an immune response. Positive sputum cultures, chest x-rays, and the presence of symptoms confirm that the client has active disease(Option C). (Option B) A second injection is not needed when the client has a positive PPD. (Option D) Placing the client in airborne precautions before confirming the presence of active TB is premature. Only clients with active TB (eg, symptoms, positive chest x-ray or sputum stain/culture) require isolation. Educational objective: A positive purified protein derivative (ie, Mantoux) response alone does not indicate active tuberculosis (TB). Confirmation of active TB will be made by positive sputum samples, chest x-ray, and the presence of symptoms.

The Nurse Assesses the Site Where a Client Received an Intradermal