The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

Massage the site gently after injection.

Ensure bevel of the needle is pointing up.

Hold the syringe perpendicular to the skin.

Select upper arm as the injection site.

Answer and Explanation

The Correct Answer is B

B. The needle should be inserted with the bevel facing up (visible through the skin). The goal is to deposit the medication into the epidermal layer (not subcutaneous tissue).

A. Massaging the site after injection can cause the medication to spread beyond the intended area, leading to inaccurate results or potential complications.

C. The correct angle for an intradermal injection is 5 to 15-degree angle. This angle allows for proper placement of the medication just below the epidermis.

D. Intradermal injections are usually administered on the forearm or the upper back, where the skin is thin and easily lifted to create a wheal.

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Correct Answer is D

Explanation

D. Neuropathy, especially when associated with numbness and tingling in the lower extremities, poses a significant risk for impaired skin integrity. The loss of sensation can lead to decreased awareness of pressure, friction, or trauma to the feet, making the client more susceptible to skin breakdown, ulcers, and injuries.

A. Increasing numbness and tingling in the lower extremities, which primarily suggests neuropathic symptoms rather than impaired mobility.

B. A self-care deficit may arise if the client's neuropathy significantly affects their ability to perform foot care tasks independently. However, self-care deficit becomes a priority concern.

C. Neuropathy can increase the risk of foot injuries due to decreased sensation, which in turn can lead to infections if not promptly addressed. However, while infection is a potential complication, the immediate concern in this scenario is preventing the development of skin breakdown and ulcers.

A. Administer PRN oral pain medication. B. Monitor the client's nonverbal behavior. C. Ask the client what is causing the grimacing. D. Review the pain medications prescribed.

Correct Answer is C

Explanation

A. Administering pain medication solely based on nonverbal cues without further assessment and confirmation of pain may lead to unnecessary medication administration and potential adverse effects.

B.Monitoring the client's nonverbal behavior is crucial in this situation because it can provide valuable insight into the client's pain experience. However, this shoudl come after listening to the client first.

C. Directly asking the client about the grimacing is a very reasonable approach. Since the client denies pain but is exhibiting nonverbal signs of discomfort, the nurse could ask specific questions to explore whether there is another underlying cause.

D. Reviewing the pain medications prescribed is important to ensure that the client is receiving appropriate pain management, but it may not be the most immediate intervention in this scenario.

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The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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