The nurse observes the arm of a patient who was given the Mantoux skin test for tuberculosis. There is induration of 3 mm. How should the nurse document the results?
a. Negative
b. Questionable
c. Positive for exposure
d. Positive for TB
ANS: A
The Mantoux test is designed to identify people with active tuberculosis, with exposure to tuberculosis, or needing further testing. Positive reaction must have erythema and induration of 9 mm or more in size; a reaction of 5 to 9 mm is questionable, and areas under 5 mm are negative.
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