A nurse is caring for a client with urinary incontinence.
What action should the nurse take to prevent skin breakdown?

The correct answer is Choice D

Choice A rationale: A 1-inch needle is typically used for intramuscular injections, not intradermal administration. Intradermal injections require a short, fine-gauge needle—usually ¼ to ⅝ inch in length and 25 to 27 gauge—to ensure accurate placement within the dermis. Using a longer needle increases the risk of injecting into subcutaneous tissue, which alters absorption and invalidates the test. Scientific technique demands precise needle selection based on anatomical depth and pharmacokinetics of the test substance.

Choice B rationale: A 20° angle is inappropriate for intradermal injections, which require a shallow angle of 5° to 15° to ensure deposition within the dermal layer. Angles greater than 15° risk penetrating into subcutaneous tissue, compromising test accuracy and absorption kinetics. The dermis is a narrow layer between the epidermis and subcutaneous fat, and precise angulation is critical for forming the characteristic wheal and ensuring localized immune response. Scientific technique mandates strict adherence to angle parameters.

Choice C rationale: The standard volume for a tuberculin skin test using purified protein derivative (PPD) is 0.1 mL, not 0.5 mL. Administering 0.5 mL would exceed the recommended dose, potentially causing excessive local reaction, invalid test results, and patient discomfort. The Mantoux method requires exact dosing to elicit a controlled immune response for accurate interpretation. Scientific protocol emphasizes precision in volume to maintain test validity and minimize adverse effects. Overdosing violates established guidelines.

Choice D rationale: Pinching or gently pulling the skin taut at the injection site stabilizes the dermal layer and facilitates correct needle placement. This technique ensures the needle enters at the proper angle and depth, allowing formation of a visible wheal, which confirms intradermal delivery. It also minimizes patient discomfort and prevents misplacement into deeper tissues. Scientific technique for intradermal injections prioritizes anatomical control and tactile feedback to optimize accuracy and diagnostic reliability.

Choice A rationale
Requesting a prescription for the insertion of an indwelling urinary catheter is not the best option to prevent skin breakdown in a client with urinary incontinence. Catheters can increase the risk of urinary tract infections and should be used as a last resort.
Choice B rationale

Applying a moisture barrier ointment to the skin can help protect the skin from the damaging effects of urine. This can help prevent skin breakdown and is a common practice in the care of clients with urinary incontinence.
Choice C rationale
Cleaning the skin and perineum with hot water after each episode of incontinence is not recommended. Hot water can dry out the skin and cause irritation. It’s better to use warm water and a gentle cleanser.
Choice D rationale
Checking the client’s skin every 8 hours for signs of breakdown is important, but it’s not the only action the nurse should take. The nurse should also take proactive measures to protect the skin, such as applying a moisture barrier ointment.