A nurse is reading the PPD test on the left arm of an inpatient client who was injected with the test material exactly 48 hours ago. The test area has a 4-mm diameter area of induration. What is the nurse's best action?
A. Institute airborne infection precautions immediately.
B. Document the observation as the only action.
C. Retest the client on the opposite arm.
D. Re-examine the test site at 72 hours.
D
An area of induration (not just redness) measuring 10 mm or more in diameter 48 to 72 hours after injection indicates exposure to and infection with TB. Recent studies indicate that a reading after 72 hours rather than after just 48 hours is more accurate. The incidence of false-negative readings is greater at 48 hours.
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