A nurse is preparing to administer a subcutaneous injection to a client. Which of the following actions should the nurse plan to take?
Cleanse the injection site with a circular motion.
Don sterile gloves prior to the injection.
Use the dominant hand to pinch the client's skin
Inject the medication at a 15° angle to the client's skin
The Correct Answer is A
A. Cleansing the injection site is important to reduce the risk of infection.
B. Sterile gloves are not typically required for administering subcutaneous injections unless there is a specific indication, such as when dealing with a client who has a compromised immune system or if there is potential for exposure to bodily fluids.
C. Pinching the skin can help in creating a fold where the needle can be inserted. However, there is no standard recommendation on which hand should be used.
D. Subcutaneous injections are typically administered at a 45-degree or 90-degree angle to the client's skin, depending on the amount of subcutaneous tissue present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Swelling around the IV site or in the extremity (such as the fingers) can be a sign of infiltration. This occurs because the IV fluid leaks into the surrounding tissues, causing localized swelling.
A. Blood backing up in the IV tubing could indicate issues like a clot in the line or a slow flow rate, but it does not specifically suggest infiltration. It might prompt the nurse to check for other issues such as patency of the IV line or the need for flushing.
C. A long red streak up the arm could indicate inflammation or infection along the vein (phlebitis) rather than infiltration. Phlebitis can be caused by mechanical irritation, chemical irritation from the IV fluids, or infection.
D. Tape coming off the IV needle suggests a need for re-securing the IV, but it does not directly indicate infiltration. However, if the tape is coming off, it's important to check the entire IV site to ensure the catheter is still properly inserted and there are no signs of infiltration or dislodgment.
Correct Answer is D
Explanation
D. Numbness and tingling of the hands and feet can indicate peripheral neuropathy, a known adverse effect of nitrofurantoin. It's essential for the nurse to recognize and communicate the potential seriousness of these symptoms to the client.
A. Numbness and tingling are not typically related to hydration status. While adequate hydration is important for overall health, it does not directly prevent numbness and tingling caused by medication side effects.
B. Symptoms like urinary frequency, burning, and dysuria are common symptoms of a urinary tract infection, not indicators of the medication working.
C Numbness and tingling of the hands and feet can be indicative of peripheral neuropathy, which is a potential adverse reaction to nitrofurantoin. While not all cases are severe, it's crucial to assess the severity and duration of these symptoms and notify the healthcare provider.
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