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 ["A","B","D"]
Explanation
A. Streak formation along the vein is a characteristic sign of phlebitis. It indicates inflammation and possibly thrombophlebitis (inflammation with clot formation) within the vein.
B. Erythema (redness) at the insertion site is a common early sign of phlebitis. It indicates localized inflammation of the vein.
C. Blistering around the insertion site is not typically associated with phlebitis. It may suggest a severe reaction or infection, but it is not a common manifestation of phlebitis itself.
D. Warmth at the insertion site is a common sign of inflammation, including phlebitis. It indicates increased blood flow and localized inflammatory response.
E. A damp dressing over the insertion site can contribute to the risk of infection but is not a direct manifestation of phlebitis. However, it can be a contributing factor to the development of phlebitis if moisture leads to skin breakdown or infection.
Correct Answer is A
Explanation
A. This indicates a slight positive fluid balance (+100 mL), meaning the client has taken in slightly more fluids than they have excreted. This could be acceptable depending on the client's clinical condition and fluid status.
B. This indicates a negative fluid balance (-500 mL), suggesting the client has excreted more fluids than they have taken in. In some situations, such as in patients with certain conditions like edema, a negative balance might be intended.
C. This indicates a significant negative fluid balance (-1,300 mL), where the client has excreted much more fluid than they have taken in. This could indicate dehydration or fluid loss that needs to be addressed promptly.
D. This indicates a significant positive fluid balance (+2,000 mL), where the client has taken in much more fluid than they have excreted. This could indicate fluid retention, which might be acceptable in certain clinical conditions but could be problematic in others, such as in patients with congestive heart failure.
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