The nurse is administering a subcutaneous injection to a client. Which of the following actions should the nurse take?

Clean skin using a side to side motion.

Keep skin pinched while injecting medication.

Apply firm pressure to the injection site.

Insert the needle at a 45 or 90-degree angle.

Answer and Explanation

Correct Answer : B,D

A. Clean skin using a side to side motion. The skin should be cleaned in a circular motion from the center outward to reduce the risk of infection.

B. Keep skin pinched while injecting medication. Pinching the skin helps create a small "pocket" for the injection, making it easier to administer the medication subcutaneously.

C. Apply firm pressure to the injection site. Applying firm pressure is not recommended immediately after the injection as it can cause discomfort and does not affect absorption. Gentle pressure is usually recommended.

D. Insert the needle at a 45 or 90-degree angle. For subcutaneous injections, a 45-degree angle is often recommended for thinner individuals, while a 90-degree angle is appropriate for those with more tissue.

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Correct Answer is A

Explanation

A. "You sound frustrated, tell me more about this feeling." This response validates the patient’s feelings and opens up a discussion about their emotions, which provides support and helps address their psychological needs.

B. "You remind me of my mother, she is always frustrated when she is ill." This response is not focused on the patient’s needs and shifts attention away from their concerns.

C. "I am concerned about your mental health; I will call your family." While mental health is important, calling the family without first addressing the patient’s immediate concerns might feel intrusive or premature.

D. "You need to be more careful after this stroke or you could fall." This response addresses safety but does not provide emotional support or acknowledge the patient’s feelings of frustration.

A. Acute pain B. Risk for injury C. Activity Intolerance D. Toileting self-care deficit

Correct Answer is B

Explanation

A. Acute pain: This diagnosis might be relevant if the patient has pain, but it does not address the main concern of mobility and risk related to recent falls.

B. Risk for injury: This is the most appropriate diagnosis as the patient’s inability to bear weight and recent falls increase their risk of further injury.

C. Activity Intolerance: While the patient may have activity intolerance, the more pressing concern related to their recent falls and inability to bear weight is the risk for injury.

D. Toileting self-care deficit: This diagnosis might be relevant if there were specific issues with toileting, but it is not the most appropriate for the general risk of injury due to recent falls.

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The nurse is administering a subcutaneous injection to a client. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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