A nurse is preparing to administer an intradermal tuberculin test to a client. Which of the following actions should the nurse take?
Advance the needle 6 mm (7 in) below the skin's surface.
Point the bevel of the needle upward prior to insertion.
Administer the injection on the dorsal forearm.
Insert the needle at a 20° angle to the client's skin.
The Correct Answer is B
A. Advance the needle 6 mm (7 in) below the skin's surface: Intradermal injections should be administered just beneath the skin, not deeply. The needle should be inserted at an angle to form a small bleb just below the epidermis. This depth ensures proper absorption.
B. Point the bevel of the needle upward prior to insertion: The bevel should be facing upward when performing an intradermal injection to ensure the medication is injected just below the skin surface. This positioning helps form a visible wheal or bleb, which is necessary for the tuberculin test.
C. Administer the injection on the dorsal forearm: The recommended site for an intradermal tuberculin test is the inner aspect of the forearm, not the dorsal forearm. The inner forearm provides a flatter surface for easy visualization of the wheal.
D. Insert the needle at a 20° angle to the client's skin: An intradermal injection should be administered at a 5-15° angle to ensure the needle is positioned just beneath the skin’s surface. A 20° angle may result in the injection being too deep.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Place a vibrating tuning fork against the midline vertex of the client's head: The Weber test is performed by placing a vibrating tuning fork on the midline of the client's forehead or vertex of the head. This tests for lateralization of sound, helping to distinguish between conductive and sensorineural hearing loss based on which ear hears the sound louder.
B. Have the client repeat a phrase spoken by the nurse while the nurse's mouth is hidden: This action refers to the "speech discrimination test" rather than the Weber test. It is not part of the Weber test, which is specifically used to assess the lateralization of sound.
C. Whisper words for the client to identify: This refers to a different hearing test, called the "whisper test," used to assess hearing ability, not the Weber test. The Weber test specifically uses a tuning fork to assess how sound is heard by the client.
D. Ask the client to occlude one ear with a finger: While blocking one ear can be used in other tests (like Rinne's test), it is not necessary for the Weber test, which involves placing the tuning fork in the center of the head.
Correct Answer is A
Explanation
A. Offer a wet washcloth for the client to wash their face: Washing the face with a wet washcloth can promote relaxation and help signal to the body that it’s time to wind down. This calming routine can be soothing and may help improve the client’s ability to fall asleep.
B. Perform range-of-motion exercises: Doing range of motion exercises shortly before bedtime can be overstimulating. Physical activity close to bedtime may increase alertness and make it harder for the client to fall asleep.
C. Prepare hot cocoa or tea for the client: While warm drinks might seem comforting, caffeine in some teas or high sugar in hot cocoa can interfere with sleep. It’s important to avoid stimulants and opt for calming beverages, such as caffeine-free herbal teas, instead.
D. Provide a late supper: A large meal late at night can be disruptive to sleep as it may cause indigestion or discomfort. It’s better to encourage lighter, earlier meals to prevent any disturbances that could affect the client’s ability to fall asleep.
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