A nurse is caring for a client who is receiving continuous IV therapy.

Exhibits

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Based on the client's manifestations, they developed

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and

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Rationale

A. Advance the needle 6 mm (1/4 in) below the skin's surface: The needle should not be advanced below the dermis because intradermal injections require placement within the superficial skin layers. Advancing too deeply can result in subcutaneous injection, which may produce a false-negative result.

B. Insert the needle at a 20° angle to the client's skin: Intradermal injections should be administered at a very shallow angle, typically 5–15°, to ensure proper placement just under the epidermis. A 20° angle risks injecting too deeply and compromising test accuracy.

C. Point the bevel of the needle upward prior to insertion: Keeping the bevel upward allows for smooth entry into the dermis and helps form a visible wheal, which is necessary to confirm correct intradermal placement. This technique minimizes tissue trauma and ensures the test can be accurately read.

D. Administer the injection on the dorsal forearm: The recommended site for a tuberculin skin test is the inner surface of the forearm, not the dorsal side. The inner forearm provides a flat, easily accessible area that allows for accurate observation and measurement of induration.

Rationale

A. Bounding pulse: A full, strong, or bounding pulse is a classic sign of fluid volume excess due to increased circulating blood volume. The elevated intravascular pressure causes the heart to eject blood more forcefully, making the pulse more palpable. Assessing pulse quality helps identify hypervolemia and monitor cardiovascular status.

B. Polyuria: Polyuria is more commonly associated with fluid volume excess caused by conditions like diabetes insipidus or use of diuretics, but it is not a primary manifestation in general hypervolemia. Fluid overload typically results in edema and decreased urinary output if the kidneys are unable to compensate.

C. Weight loss: Weight loss indicates fluid volume deficit rather than excess. Fluid retention in hypervolemia usually presents as rapid weight gain, which reflects increased total body water and extracellular fluid accumulation. Monitoring daily weight is key to assessing fluid status.

D. Dry mucous membranes: Dry mucous membranes are characteristic of dehydration or fluid volume deficit. In fluid volume excess, mucous membranes may appear moist, and edema may be present due to fluid accumulation in tissues. Evaluating mucous membranes helps differentiate between overhydration and dehydration.