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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A rationale
Cranberry juice is an acceptable component of a clear liquid diet. Clear liquid diets are often prescribed postoperatively as they are easy to digest and leave no residue in the digestive tract.
Choice B rationale
Lemon sherbet is not part of a clear liquid diet. It is considered part of a full liquid diet, which is more substantial and includes foods that are liquid at room temperature.
Choice C rationale
Carrot juice is not typically included in a clear liquid diet. It may contain pulp and is not clear, which is a requirement of a clear liquid diet.
Choice D rationale
Plain yogurt is not part of a clear liquid diet. It is considered a solid food and is therefore not included.
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