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 B

Explanation

B. This timing is based on the gastrocolic reflex, which typically triggers bowel movements shortly after eating. By assisting the client to the commode after meals, the nurse can take advantage of this reflex and increase the likelihood of successful bowel evacuation, reducing the risk of fecal incontinence episodes.

A. Incontinence briefs can provide containment for fecal incontinence and help manage soiling of clothing and bedding. However, they do not address the underlying issue of fecal incontinence or contribute to bowel training.

C. Administering a glycerin suppository after meals may stimulate bowel movements, but it does not address the underlying causes of fecal incontinence or promote bowel training.

D. Inserting a rectal tube at specified intervals may be indicated for fecal management in certain clinical situations, but it is not typically used as a primary intervention for bowel training in clients with chronic fecal incontinence.

A. Bears body weight on the palms of hands during the crutch gait. B. Progresses to foot touchdown and weight bearing of affected leg. C. Practices bicep and triceps isometric exercises. D. Inspects crutches to ensure rubber tips are intact.

Correct Answer is B

Explanation

B. In three-point gait crutch walking, the client should progress to foot touchdown and weight bearing of the affected leg. This means that the client is able to advance the crutches forward, followed by the affected leg, and then the unaffected leg. The weight should be borne primarily by the hands and arms on the crutches while the affected leg supports some weight as tolerated.

A. Bearing body weight on the palms of hands during the crutch gait describes the correct distribution of weight on the crutches, which is important for proper technique, but it does not specifically address the coordination of crutch and leg movements in three-point gait.

C. Practices bicep and triceps isometric exercises is not directly related to proper crutch walking technique but may be beneficial for strengthening the upper extremities, which are involved in using crutches.

D. Inspects crutches to ensure rubber tips are intact is important for safety but does not specifically indicate understanding of proper crutch walking technique.

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

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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