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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The Trendelenburg position is not indicated for increasing oxygen saturation and could be harmful, especially for clients with respiratory distress.
Choice B reason: Ensuring that the prongs of the nasal cannula are securely placed in the nostrils is important for effective oxygen delivery, especially if the oxygen saturation remains below the prescribed range.
Choice C reason: Placing the pulse oximeter on the client's earlobe is an alternative site for obtaining a saturation reading, but it does not address the issue of potentially inadequate oxygen delivery.
Choice D reason: While documentation is important, the nurse must first address the low oxygen saturation levels before documenting the readings.

Correct Answer is C
Explanation
Choice A reason: This response is inappropriate and dismissive of the sibling's concern and the client's need for communication assistance.
Choice B reason: Providing medical information to someone who is not an approved interpreter could breach confidentiality and privacy regulations.
Choice C reason: It is important to use an approved interpreter to ensure accurate and confidential communication of medical information.
Choice D reason: While the healthcare provider will share information, it is essential to use an approved interpreter to facilitate understanding and maintain confidentiality.
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