Which nursing assessment indicates a positive reading of a tuberculin (TB) skin test?
Explanation & Rationale
A. 5 days after injection with a 2-mm area of redness and swelling: A 2-mm reaction is considered negative. Redness alone is not sufficient to indicate a positive tuberculin skin test, and the reading should be based on induration, not erythema. B. 4 days after injection with a 3-mm area of redness and swelling: A 3-mm induration is below the threshold for a positive result for most populations. Additionally, the test should ideally be read 48–72 hours after administration, so a 4-day reading may be inaccurate. C. 2 days after injection with a 5-mm area of redness and swelling: A 5-mm induration can be considered positive in high-risk individuals, such as those with immunocompromising conditions. Reading the test 48–72 hours post-injection is appropriate, making this the correct interpretation. D. 1 day after injection with a 10-mm area of redness and swelling: Reading the test at 24 hours is too early. The reaction may not have fully developed, and assessment should be done between 48–72 hours to ensure accuracy.