HESI V3 Nursing Transition: TB Testing, Triage, and Palliative Care Guide

Positive Test for TB

Positive Result:

• Induration greater than 15mm: Considered positive for TB. Assess the raised area rather than erythema

Conditional Positive Result:

• Induration between 10-15mm: May be positive in individuals with risk factors, including:
  • Born in a country with high TB prevalence
  • African American, Hispanic, or Asian American individuals in poverty areas
  • Injectable drug users
  • Long-term care patients
  • Those with medical risk factors such as malnutrition or diabetes mellitus

Cautionary Positive Result:

• Induration between 5-9mm: May indicate TB in individuals who:
  • Have close contact with TB-infected patients
  • Show abnormalities on chest X-rays
  • Are HIV-infected

Disaster Training - Focus on Safety & Triage

• Nurse safety is the first priority
• Triage Color Codes:
  • Red: First priority, immediate treatment
  • Yellow: Systemic injuries, treatment needed within 30-60 minutes
  • Green: Minor injuries, can wait several hours
  • Black: No hope for recovery, palliative care is appropriate

Palliative Care for Multiple Sclerosis (MS):

• Patient has difficulty swallowing, is dehydrated, and has declined IV fluids
• Focus on comfort care
• Key intervention: Administer medication as needed to manage pain and anxiety

Pediatric Hair Loss (PEDIAlopecia):

Frictional Hair Loss:

• Abnormal hair loss is often seen on the back of the head in infants who lie on their backs in a crib