D. Holding the skin taut helps stabilize the area and ensures that the needle penetrates the skin smoothly and at the correct angle. This also helps prevent the needle from going too deep or slipping out of the site during injection.

A. The syringe should be held at a 5 to 15-degree angle to the client's skin, not 20 degrees.

B. For a tuberculin skin test (PPD test), typically 0.1 mL (one-tenth of a milliliter) of PPD is injected intradermally. This is a very small amount compared to 0.5 mL.

C. The length of the needle for an intradermal injection is typically shorter than 1 inch, usually around 3/8 to 5/8 inches (10-16 mm). Using a longer needle may increase the risk of inserting the needle too deeply, potentially leading to subcutaneous rather than intradermal injection.

To administer a dose of 250 mg of amoxicillin when only 125 mg tablets are available, the nurse would need to give two tablets. This is because each tablet contains 125 mg, and two tablets would equal the required dose of 250 mg

B When drawing medication from an ampule, especially if it's a solution that may contain particulate matter or to ensure sterility, using a filter needle is recommended. A filter needle has a membrane filter that prevents particles from being drawn into the syringe while allowing the medication to pass through.

A. Shaking a glass ampule is not recommended because it can lead to the introduction of glass particles or cause the solution to foam or become contaminated. Instead, gently flicking the ampule with a finger can help move any solution that may be adhering to the neck downward, but shaking should be avoided.

C. While wearing gloves is important for infection control, sterile gloves are not typically required for withdrawing medication from a single-dose glass ampule. Standard aseptic technique and hand hygiene are usually sufficient.

D. Ampules are designed to be opened by snapping the top away from the body to avoid potential injury from glass shards. The nurse should use a gauze pad or an ampule opener to break the ampule open safely, directing any breakage away from themselves and others.

C. This method is recommended because it is less painful, as the sides of the fingertips have fewer nerve endings compared to the pads or 'balls' of the fingers.

A. Avoiding the use of the thumbs is not necessary unless they are calloused or used frequently for other tasks that could affect sensitivity.

B. Avoiding the use of the dominant hand's fingers are not necessary unless they are calloused or used frequently for other tasks that could affect sensitivity.

D. Using the ball of the finger is not recommended for blood glucose monitoring because it can be more painful and may lead to less blood flow, resulting in difficulty obtaining an adequate blood sample.

D Excessive use of bisacodyl or other laxatives can indeed cause these adverse effects. Rectal burning can occur due to irritation from frequent bowel movements, while dehydration and electrolyte imbalance can result from fluid loss caused by frequent laxative use.

A. While regular bowel movements are important for many individuals, daily bowel movements are not necessary for everyone and can vary depending on diet, hydration, and individual health conditions.

B. Bisacodyl is a stimulant laxative used for short-term relief of constipation. It does not interact with dietary fiber intake, nor should the client necessarily decrease high-fiber foods unless specifically advised by their healthcare provider for other reasons.

C. Chronic use of bisacodyl, a stimulant laxative, can indeed lead to dependence and potentially harmful effects on the body's water and salt balance

B. Swelling around the IV site or in the extremity (such as the fingers) can be a sign of infiltration. This occurs because the IV fluid leaks into the surrounding tissues, causing localized swelling.

A. Blood backing up in the IV tubing could indicate issues like a clot in the line or a slow flow rate, but it does not specifically suggest infiltration. It might prompt the nurse to check for other issues such as patency of the IV line or the need for flushing.

C. A long red streak up the arm could indicate inflammation or infection along the vein (phlebitis) rather than infiltration. Phlebitis can be caused by mechanical irritation, chemical irritation from the IV fluids, or infection.

D. Tape coming off the IV needle suggests a need for re-securing the IV, but it does not directly indicate infiltration. However, if the tape is coming off, it's important to check the entire IV site to ensure the catheter is still properly inserted and there are no signs of infiltration or dislodgment.

D. After administering the PPD solution intradermally, the nurse should not withdraw the needle and massage the site. Massaging can cause the PPD to disperse outside the intended area and affect the accuracy of the test result. Instead, the nurse should gently blot the site with a gauze pad if there is any bleeding, without massaging.

A. For a Mantoux tuberculin skin test, the standard technique involves injecting a small amount of tuberculin purified protein derivative (PPD) intradermally to create a wheal or bleb that is typically 6 mm in diameter. If the nurse creates a bleb significantly larger or smaller than the recommended size, it could affect the interpretation of the test result.

B. It's important to avoid visualizing the needle tip under the skin during the injection. This can lead to inaccurate placement of the PPD solution, potentially resulting in an improperly administered test.

C. Stretching the skin tightly before injection is actually a correct technique for performing a Mantoux tuberculin skin test. This helps stabilize the injection site and ensures the needle is inserted at the correct angle for an intradermal injection.

B. Dextrose 10% in water is a solution that contains a high concentration of glucose (dextrose). Infusing D10W can lead to an increase in blood glucose levels, especially if the client's body cannot metabolize the glucose effectively (e.g., in diabetic patients or those with impaired glucose tolerance).

A. Dextrose 10% in water does not contain calcium. Hypercalcemia refers to elevated calcium levels in the blood, which can occur due to various causes such as hyperparathyroidism or excessive vitamin D intake, but not from D10W infusion.

C. Dextrose 10% in water is not used to treat hypovolemia (low blood volume). It is a solution primarily used to provide calories and prevent ketosis rather than to expand circulating blood volume.

D. Dextrose 10% in water does not contain potassium. Hypokalemia (low potassium levels) can occur due to various reasons such as diuretic use, gastrointestinal losses, or inadequate intake, but it is not directly related to D10W infusion.

B. This is the highest priority. Before administering ceftriaxone via IV piggyback, the nurse must ensure compatibility with the primary IV solution (D5W with KCl). Certain medications can interact chemically or physically with other IV solutions or medications, leading to precipitation, inactivation, or other adverse effects. Compatibility should be verified through appropriate resources or pharmacy guidelines.

A. Vital signs provide crucial information about the patient's overall condition, but they do not directly impact the administration of the IV medication ceftriaxone. However, if there are significant changes in vital signs (e.g., fever, hypotension), these could influence the decision to administer ceftriaxone or any medication.

C. Important, but not directly related to medication administration. The patient's level of consciousness is crucial for assessing their neurological status and response to treatment, but it does not affect the administration of ceftriaxone IV piggyback specifically.

D. Important, but not the highest priority in this context. Monitoring the amount of IV solution in the primary bag is essential to ensure continuous fluid delivery and prevent interruptions in therapy.

However, for the immediate preparation and administration of ceftriaxone IV piggyback, ensuring compatibility with the primary IV solution takes precedence.

A. Leaving small air bubbles in the new infusion tubing is incorrect. Air bubbles should be primed out of the tubing before use to prevent air embolism.

B. Inserting the new device distal to the old IV site is incorrect. The new IV site should be placed proximal to the old site to avoid complications from previous catheter use and ensure proper circulation.

C. Wearing clean gloves during the new IV insertion is correct. Clean gloves are appropriate when inserting a new short peripheral IV device. Sterile gloves are generally required for more invasive procedures, but when changing the device itself, clean gloves are sufficient.

D. Shaving the hair on the client's skin before inserting the new IV is incorrect. Shaving the skin is not recommended because it can cause small nicks that increase the risk of infection. Clipping the hair, if necessary, is the preferred method.