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 B
Explanation
A. Leave resuscitation equipment and supplies at the bedside: This can be distressing for the family. Removing such equipment before the family views the body promotes a more peaceful environment.
B. Hold the client's eyelids closed until they remain shut: This is part of postmortem care to maintain a natural appearance. It shows respect and helps prepare the body before the family views it.
C. Apply identification tags to the client's extremities: While necessary, identification tagging is not a priority before the family views the body. It is typically done before transport to the morgue.
D. Keep the head of the bed flat: Elevating the head of the bed slightly helps prevent discoloration due to blood pooling and gives the body a more natural appearance. Keeping it flat is not ideal.
Correct Answer is C
Explanation
A. Add water during tube flushes: Adding water during tube flushes is important for maintaining tube patency and hydration but does not directly address diarrhea. It is not a primary solution for managing diarrhea caused by enteral feedings.
B. Change to an enteral formula that has added fiber: While fiber can help regulate bowel movements, changing to a formula with added fiber is not the first intervention for diarrhea. A slow-down of the feeding rate may be more effective to allow the digestive system more time to process the formula.
C. Slow down the instillation flow rate: Slowing down the flow rate of the enteral feeding can reduce the likelihood of diarrhea. A rapid infusion rate can overwhelm the intestines and lead to diarrhea, so adjusting the flow rate is an appropriate first step.
D. Add yogurt to enteral feedings: While yogurt contains probiotics that might help with gut health, adding it to the feeding may not be advisable unless specifically indicated. The primary step for managing diarrhea is adjusting the flow rate of the feeding.
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