A nurse is administering an intradermal injection to a patient. Which statements are correct? Select all that apply.
A depressed area around the injection sites indicates a positive reaction.
After the insertion of the needle, a healthcare provider should aspirate for a blood return.
The needle is inserted with the bevel of the needle upward at a 10- to 15-degree angle.
The inner arm or upper back are the preferred sites.
Correct Answer : C,D
These statements are correct because they follow the guidelines for intradermal injections, which are used for skin testing, such as for allergies or tuberculosis. Intradermal injections are given into the dermis, which is the layer of skin below the epidermis.
The needle is inserted with the bevel of the needle upward at a 10- to 15-degree angle to ensure that the medication is delivered into the dermis and not into the subcutaneous tissue or the epidermis. The bevel is
the slanted part of the needle tip that creates a sharp point. Inserting the needle with the bevel upward also reduces tissue trauma and bleeding.
The inner arm or upper back are the preferred sites for intradermal injections because they have thin skin and minimal hair, which makes it easier to see and measure any reactions. The inner arm is usually used for adults, while the upper back is used for children.
The other statements are not correct because they do not apply to intradermal injections or they contain false information.
a. A depressed area around the injection sites indicates a positive reaction. This statement is false because a depressed area, also known as induration, indicates a negative reaction. A positive reaction is indicated by a raised area, also known as a wheal, that is larger than a certain size depending on the type of test.
b. After the insertion of the needle, a healthcare provider should aspirate for a blood return. This statement does not apply to intradermal injections because aspiration is not necessary for this type of injection. Aspiration is the process of pulling back on the plunger of the syringe to check for blood in the needle before injecting the medication. This is done to avoid injecting into a blood vessel, which can cause adverse effects or reduce the effectiveness of the medication. However, intradermal injections are given into very superficial layers of skin where there are no blood vessels, so aspiration is not required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This action should be taken by the nurse before administering the medication because the use of a trailing zero after a decimal point (5.0 mg) is a common cause of medication errors and should be avoided. A trailing zero may be misread or misinterpreted as a larger dose (50 mg) or omited altogether, resulting in a 10-fold overdose or underdose, respectively. For example, when prescriptions have been writen for "Coumadin 1.0 mg," patients have received 10 mg in error. Therefore, the nurse should clarify the intended dose with the healthcare provider and use the correct notation (5 mg) without a trailing zero.
The other options are not appropriate actions because:
a) Discussing the use of PO (by mouth) with the healthcare provider is not necessary, as PO is a standard route of administration for Haldol (haloperidol) and does not pose a risk of confusion or error.
b) Discussing the use of tid (three times a day) with the healthcare provider is not necessary, as tid is a standard frequency of administration for Haldol and does not pose a risk of confusion or error.
c) Discussing the use of Haldol with the healthcare provider is not relevant to the question, as Haldol is the prescribed medication for the patient who is agitated and does not need to be changed or questioned by the nurse.
Correct Answer is A
Explanation
The flow rate of infusion is 125 mL/hr.
This answer is correct because it is based on a simple division and rounding calculation. The nurse should follow these steps to determine the flow rate of infusion:
1) Subtract the start time of the infusion from the end time of the infusion to get the duration of the infusion in hours and minutes, as follows:
15:45 - 06:57 = 8:48
Therefore, the infusion lasted for 8 hours and 48 minutes.
2) Convert the duration of the infusion to hours only by dividing the minutes by 60, since there are 60 minutes in 1 hour. Add this to the hours, as follows:
8 + (48 / 60) = 8.8
Therefore, the infusion lasted for 8.8 hours.
3) Divide the volume of the infusion by the duration of the infusion to get the flow rate in milliliters per hour, as follows:
1000 mL / 8.8 hr = 113.64 mL/hr
Therefore, the flow rate is 113.64 mL/hr.
4) Round the flow rate to the nearest whole number, as follows:
113.64 mL/hr ≈ 114 mL/hr
Therefore, the flow rate is approximately 114 mL/hr.
5) Adjust the flow rate to a standard value that can be set on an IV pump or gravity drip chamber, as follows:
114 mL/hr → 125 mL/hr
Therefore, the flow rate of infusion is 125 mL/hr.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.