A client receives a tuberculin (PPD) skin test on Thursday at 1200. The nurse documents on the medication record that the results need to be read:

The tuberculin skin test (TST), also known as the Mantoux test, is used to determine if a person has been infected with the tuberculosis (TB) bacteria. The test involves injecting a small amount of purified protein derivative (PPD) into the skin of the forearm. The injection site is then examined 48 to 72 hours later for a reaction, which is measured in millimeters of induration (swelling).

Choice A reason:

Sunday morning is the correct time to read the test results. Since the test was administered on Thursday at 1200, the 48 to 72-hour window for reading the results would fall between Saturday at 1200 and Monday at 1200. Reading the results on Sunday morning falls within this time frame, making it the appropriate choice.

Choice B reason:

Saturday morning is not the correct time to read the test results. Reading the test results on Saturday morning would be less than 48 hours after the test was administered, which is too early to accurately assess the reaction. The test needs to be read between 48 and 72 hours after administration to ensure accurate results.

Choice C reason:

Friday morning is also not the correct time to read the test results. Reading the test results on Friday morning would be only 24 hours after the test was administered, which is far too early. The immune response to the PPD injection takes time to develop, and reading the test too early can result in a false-negative result.

Choice D reason:

Monday morning is within the acceptable time frame to read the test results, but it is at the very end of the 72-hour window. While it is still technically correct, it is generally recommended to read the test closer to the 48-hour mark to ensure the most accurate results. Therefore, Sunday morning is a better choice.

Choice A reason: Suctioning the client at least every two hours is not typically necessary for a non-productive cough. Suctioning is more appropriate for patients with excessive secretions that they cannot clear on their own. Overuse of suctioning can cause irritation and discomfort.

Choice B reason: Encouraging fluids up to 3000 mL/day unless contraindicated is crucial for a client with pneumonia. Adequate hydration helps to thin mucus, making it easier to expectorate and clear from the lungs. This can improve the client’s ability to cough effectively and reduce the risk of complications such as atelectasis. Hydration also supports overall bodily functions and helps in maintaining electrolyte balance.

Choice C reason: Encouraging a right side-lying position is not the best intervention for a client with right lower lobe pneumonia. This position may not promote optimal lung expansion and drainage. Instead, positioning the client to maximize lung expansion and facilitate drainage, such as sitting up or lying on the unaffected side, is more beneficial.

Choice D reason: Administering codeine elixir PRN following prescription is not the priority intervention. While codeine can help suppress a cough, it is generally not recommended for a non-productive cough in pneumonia because it can suppress the cough reflex needed to clear secretions. Additionally, codeine can cause respiratory depression and other side effects.