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 A
Explanation
Choice A reason: Before initiating tube feeding, it is crucial to ensure that the gastrointestinal system is functioning. The presence of bowel sounds indicates peristalsis, which is necessary for the digestion and absorption of the feeding.
Choice B reason: While measuring the client's total body weight is important for overall assessment and monitoring of nutritional status, it is not the most critical assessment before starting tube feeding.
Choice C reason: Evaluating the client's ability to swallow is not relevant in this scenario since the client will be receiving nutrition through a feeding tube due to malnutrition and dehydration.
Choice D reason: Observing for signs of fluid volume deficit is important, but the immediate concern before starting tube feeding is to confirm gastrointestinal activity through the presence of bowel sounds.
Correct Answer is C
Explanation
Choice A reason: Using normal saline to irrigate the wound is a correct practice and does not indicate a need for additional teaching. Normal saline is isotonic and is commonly used for wound irrigation because it does not interfere with the natural healing process.
Choice B reason: Cleaning from less soiled to more soiled areas is also a correct technique to prevent contamination of cleaner areas. This method helps to reduce the risk of infection and is a standard practice in wound care.
Choice C reason: Opening a sterile package towards the body is incorrect and indicates that additional teaching is needed. When opening a sterile package, it should be opened away from the body to maintain the sterility of the contents and prevent contamination.
Choice D reason: Placing soiled dressing in a plastic bag is a proper disposal method and does not indicate a need for additional teaching. It is important to properly dispose of soiled dressings to prevent the spread of infection.
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