A nurse is preparing to administer an intradermal injection for a client who requires a tuberculin skin test. What actions should the nurse plan to take?

Place a 1-inch needle on the syringe.

Hold the syringe at a 20° angle to the client’s skin.

Draw up 0.5 mL of purified protein derivative (PPD) from the vial.

Pinch the skin at the chosen site with the non-dominant hand before inserting the needle.

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is A

Explanation

The correct answer is choice A: Provide an adaptive feeding device for the client.

Choice A rationale: Providing an adaptive feeding device, such as a built-up utensil or a swivel spoon, can help clients with limited hand movement feed themselves independently. These devices are designed to make grasping and manipulating utensils easier, promoting independence and self-care.

Choice B rationale: Placing the client in a lateral position might not directly address the issue of limited hand movement, and it could even make feeding more challenging. This position is typically used for clients with swallowing difficulties or those at risk of aspiration.

Choice C rationale: Arranging food groups clockwise on the plate may help clients with visual impairments or cognitive issues, but it would not directly assist a client with limited hand movement during feeding.

Choice D rationale: Initiating a liquid diet for the client is not the most appropriate initial action to address limited hand movement. This might be considered as a last resort if the client is unable to feed themselves with any type of adaptive device or assistance. The priority should be promoting independence and providing appropriate tools to support self-feeding.

A. Lock the wheels of the bed and the wheelchair. B. Elevate the bed to a position of comfort for the nurse. C. Get the help of several staff members to lift the client. D. Place the wheelchair at a 90° angle to the bed.

Correct Answer is B

Explanation

Choice A rationale
Locking the wheels of the bed and the wheelchair is an important safety measure when assisting a client to move from the bed to a wheelchair. However, this action alone is not sufficient. The nurse also needs to ensure the client’s safety during the transfer by using proper body mechanics and providing adequate support.
Choice B rationale
Elevating the bed to a position of comfort for the nurse is the correct action. This helps to ensure that the nurse can maintain proper body mechanics during the transfer, reducing the risk of injury to both the nurse and the client.
Choice C rationale
Getting the help of several staff members to lift the client is not typically necessary when transferring a client with generalized weakness from the bed to a wheelchair. With proper positioning and technique, one nurse can often safely assist the client with this type of transfer.
Choice D rationale
Placing the wheelchair at a 90° angle to the bed is not the recommended position when transferring a client from the bed to a wheelchair. Instead, the wheelchair should be positioned parallel to the bed or at a slight angle.

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A nurse is preparing to administer an intradermal injection for a client who requires a tuberculin skin test. What actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client whose hand movement is limited. What action should the nurse take to assist the client with feeding?

Correct Answer is A

Explanation

A nurse is assisting a client who has generalized weakness to move from the bed to a wheelchair. What actions should the nurse take?

Correct Answer is B

Explanation

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