A nurse is preparing to administer an intradermal injection for a client who requires a tuberculin skin test. What actions should the nurse plan to take?

Place a 1-inch needle on the syringe.

Hold the syringe at a 20° angle to the client’s skin.

Draw up 0.5 mL of purified protein derivative (PPD) from the vial.

Pinch the skin at the chosen site with the non-dominant hand before inserting the needle.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Placing a 1-inch needle on the syringe is not appropriate for an intradermal injection such as a tuberculin skin test. Intradermal injections require a much shorter needle, typically 1/4 to 1/2 inch in length.
Choice B rationale
Holding the syringe at a 20° angle to the client’s skin is not correct for an intradermal injection. For an intradermal injection, the syringe should be held at a much shallower angle, typically about 5 to 15 degrees.
Choice C rationale

Drawing up 0.1 mL of purified protein derivative (PPD) from the vial is the correct action when preparing to administer a tuberculin skin test. This is the standard amount of PPD used for a tuberculin skin test.
Choice D rationale
Pinching the skin at the chosen site with the non-dominant hand before inserting the needle is not typically done for an intradermal injection. Instead, the skin is usually stretched taut to provide a flat surface for the injection.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A rationale
Placing a bath seat in the shower is a good safety measure for a patient with a history of falls. It allows the patient to sit while bathing, reducing the risk of slipping and falling.
Choice B rationale

Keeping the fluorescent ceiling light on in the room at night can actually increase the risk of falls. It can create shadows and glare that can be disorienting, especially for older adults.
Choice C rationale
Placing an area rug at the entry of the bathroom is not recommended. Rugs can easily become tripping hazards, especially if they’re not secured to the floor.
Choice D rationale
Keeping a walker at the end of the bed can be helpful for some patients, but it’s not the best indication that the patient understands home safety instructions. It’s important that the walker is used correctly and that the patient’s home is arranged to accommodate its use.

A. Turn the torso at the waist when reaching for objects. B. Use ice packs intermittently for 48 hours. C. Use 10 lb arm weights to start strengthening the back muscles. D. Stay in bed except for toileting during the first 24 hours.

Correct Answer is B

Explanation

Choice A rationale
Turning the torso at the waist when reaching for objects can actually increase the risk of back injury. It’s important to keep the back straight and bend at the knees when lifting or reaching for objects.
Choice B rationale

Using ice packs intermittently for 48 hours is a common recommendation for acute lower back pain. Ice can help reduce inflammation and numb the area, providing relief. It’s important to use the ice packs intermittently, not continuously, to avoid frostbite.
Choice C rationale
Using 10 lb arm weights to start strengthening the back muscles is not recommended for someone with acute lower back pain. Heavy lifting can exacerbate the pain and potentially cause further injury. It’s better to start with gentle, low-impact exercises and gradually increase intensity as the back heals.
Choice D rationale
Staying in bed except for toileting during the first 24 hours is not typically recommended for acute lower back pain. While rest is important, prolonged bed rest can actually lead to muscle stiffness and increased pain. It’s generally recommended to stay as active as possible without exacerbating the pain.

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A nurse is preparing to administer an intradermal injection for a client who requires a tuberculin skin test. What actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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