A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

Document the site where the medication was given.

Notify the healthcare provider of the allergic response.

Elevate the area and apply light pressure over the site.

Apply a cold pack to the area for twenty minutes.

Answer and Explanation

The Correct Answer is A

Choice A reason: The appearance of a small, round raised area, known as a wheal, is a normal reaction to an intradermal injection and should be documented.

Choice B reason: This is not an allergic response but a normal reaction to an intradermal injection, so there is no need to notify the healthcare provider.

Choice C reason: There is no need to elevate the area or apply pressure as the raised area is a normal reaction to the medication being correctly placed in the dermis.

Choice D reason: Applying a cold pack is not necessary for a normal reaction to an intradermal injection.

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Correct Answer is D

Explanation

The correct answer is choice D. Paper mask and gown.

Choice A rationale:

The stethoscope is not typically placed in a biohazard bag. It is cleaned and disinfected after each use, especially when used with a patient with an infectious disease like MRSA.

Choice B rationale:

Bed linens are usually placed in a designated linen bag, not a biohazard bag, even when the patient has an infectious disease. The linens are then laundered according to the healthcare facility’s infection control guidelines.

Choice C rationale:

A sputum specimen is typically placed in a designated specimen container, not a biohazard bag. The container is then sent to the lab for analysis.

Choice D rationale:

The paper mask and gown used while caring for a patient with MRSA should be placed in a designated biohazard bag before being removed from the room. This is because these items may have come into contact with the bacteria and could potentially spread the infection.

A. Shufling gait. B. Urinary incontinence. C. Syncope when bending. D. Hand tremors.

Correct Answer is ["A","C","D"]

Explanation

The correct answer isChoice A, Choice C, and Choice D.

Choice A rationale:A shuffling gait can indicate mobility issues, making it difficult for the client to safely perform foot care and toenail clipping. This increases the risk of falls and injuries.

Choice B rationale:Urinary incontinence does not directly affect the ability to perform foot care or toenail clipping. It is more related to bladder control issues.

Choice C rationale:Syncope when bending suggests that the client may experience dizziness or fainting when bending over, making it unsafe for them to perform foot care and toenail clipping.

Choice D rationale:Hand tremors can make it challenging for the client to handle nail clippers or other tools needed for foot care, increasing the risk of injury.

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A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

Correct Answer is D

Explanation

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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