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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

C. When a client is observed using accessory muscles, it suggests increased effort in breathing, which may indicate respiratory distress or compromise. Therefore, the first vital sign the nurse should obtain is the respiratory rate to assess the client's breathing pattern and adequacy of ventilation.

A, B and D are important vitals signs in all clients. However, respiratory rate is of more concern in a client with signs of respiratory distress (use of accessory muscles).

A. Switch to a non-rebreather mask. B. Verify placement of pulse oximeter. C. Increase the oxygen to 3 L/minute. D. Remove nasal cannula.

Correct Answer is B

Explanation

B. When the oxygen saturation is lower than expected, the nurse's first action should be to verify the accuracy of the reading by ensuring the proper placement and functioning of the pulse oximeter. This involves checking that the pulse oximeter probe is securely attached to the client's finger or other appropriate site and that there are no obstructions or interference affecting the reading.

A. A non-rebreather mask delivers higher concentrations of oxygen compared to a nasal cannula and is typically used when a client requires higher levels of oxygen supplementation. However, switching to a non-rebreather mask may not be appropriate without further assessment.

C. Increasing the oxygen flow rate to 3 L/minute would deliver a higher concentration of oxygen to the client, potentially improving oxygen saturation. However, increasing the oxygen flow should be done cautiously and based on clinical assessment to avoid oxygen toxicity.

D. Removing the nasal cannula would deprive the client of supplemental oxygen, which may not be appropriate if the client's oxygen saturation is already low. Oxygen supplementation is typically provided to improve oxygenation and support vital organ function.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?

Correct Answer is C

Explanation

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via masal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

Correct Answer is B

Explanation

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?

The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Following surgery, a client expresses concern to the nurse about being able to use the bedpan. After noting that the client's prescribed postoperative activity includes getting up to a chair three times a day, how should the nurse intervene?

The nurse is entering a client's presenting problem when the computer documentation system freezes in the emergency department. Which action should the nurse perform first?

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?