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 C

Choice A rationale
Placing a 1-inch needle on the syringe is not appropriate for an intradermal injection such as a tuberculin skin test. Intradermal injections require a much shorter needle, typically 1/4 to 1/2 inch in length.
Choice B rationale
Holding the syringe at a 20° angle to the client’s skin is not correct for an intradermal injection. For an intradermal injection, the syringe should be held at a much shallower angle, typically about 5 to 15 degrees.
Choice C rationale

Drawing up 0.1 mL of purified protein derivative (PPD) from the vial is the correct action when preparing to administer a tuberculin skin test. This is the standard amount of PPD used for a tuberculin skin test.
Choice D rationale
Pinching the skin at the chosen site with the non-dominant hand before inserting the needle is not typically done for an intradermal injection. Instead, the skin is usually stretched taut to provide a flat surface for the injection.

Nursing Test Bank

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Correct Answer is D

Explanation

Choice A rationale
Tachycardia is not a common adverse effect of oxygen therapy. It is more likely to be associated with conditions such as fever, anemia, or hypoxia.
Choice B rationale
Poor skin turgor is a sign of dehydration, not a typical adverse effect of oxygen therapy. Oxygen therapy does not directly affect the body’s hydration status.
Choice C rationale
Excessive pulmonary secretions are not a direct adverse effect of oxygen therapy. Conditions such as pneumonia or bronchitis often cause increased secretions.

Choice D rationale
Cracks in the oral mucous membranes can occur as a result of oxygen therapy. Oxygen can dry out the mucous membranes, leading to discomfort and potential cracking.

A. Manifestations of hypoglycemia B. IV insertion site C. The client’s oral intake D. Height of the IV pole

Correct Answer is B

Explanation

Choice A rationale
While manifestations of hypoglycemia are important to monitor in clients receiving insulin or oral hypoglycemic agents, they are not typically a primary concern in clients receiving TPN. TPN solutions contain dextrose, which can actually lead to hyperglycemia if not properly managed.
Choice B rationale

Monitoring the IV insertion site is crucial in clients receiving TPN. Infections and complications can occur at the site of insertion, so regular assessment is necessary. Therefore, Choice B is the correct answer.
Choice C rationale
The client’s oral intake is not a primary concern when receiving TPN, as TPN provides complete nutrition intravenously.
Choice D rationale
The height of the IV pole does not need to be monitored in clients receiving TPN. The infusion pump controls the rate of the TPN infusion.

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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 patient with pneumonia who has been on oxygen therapy for several days. Which of the following symptoms should the nurse recognize as a potential adverse effect of oxygen therapy?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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