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 D

The correct answer is Choice D

Choice A rationale: A 1-inch needle is typically used for intramuscular injections, not intradermal administration. Intradermal injections require a short, fine-gauge needle—usually ¼ to ⅝ inch in length and 25 to 27 gauge—to ensure accurate placement within the dermis. Using a longer needle increases the risk of injecting into subcutaneous tissue, which alters absorption and invalidates the test. Scientific technique demands precise needle selection based on anatomical depth and pharmacokinetics of the test substance.

Choice B rationale: A 20° angle is inappropriate for intradermal injections, which require a shallow angle of 5° to 15° to ensure deposition within the dermal layer. Angles greater than 15° risk penetrating into subcutaneous tissue, compromising test accuracy and absorption kinetics. The dermis is a narrow layer between the epidermis and subcutaneous fat, and precise angulation is critical for forming the characteristic wheal and ensuring localized immune response. Scientific technique mandates strict adherence to angle parameters.

Choice C rationale: The standard volume for a tuberculin skin test using purified protein derivative (PPD) is 0.1 mL, not 0.5 mL. Administering 0.5 mL would exceed the recommended dose, potentially causing excessive local reaction, invalid test results, and patient discomfort. The Mantoux method requires exact dosing to elicit a controlled immune response for accurate interpretation. Scientific protocol emphasizes precision in volume to maintain test validity and minimize adverse effects. Overdosing violates established guidelines.

Choice D rationale: Pinching or gently pulling the skin taut at the injection site stabilizes the dermal layer and facilitates correct needle placement. This technique ensures the needle enters at the proper angle and depth, allowing formation of a visible wheal, which confirms intradermal delivery. It also minimizes patient discomfort and prevents misplacement into deeper tissues. Scientific technique for intradermal injections prioritizes anatomical control and tactile feedback to optimize accuracy and diagnostic reliability.

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Correct Answer is B

Explanation

Step 1 is: The prescribed dose is 100 mcg and each tablet contains 50 mcg.
Step 2 is: Divide the prescribed dose by the amount per tablet. So, 100 mcg ÷ 50 mcg/tablet. Step 3 is: The result is 2 tablets.

A. Assist the guest to the floor and begin mouth-to-mouth resuscitation. B. Perform the Heimlich maneuver on the guest. C. Observe the guest before taking further action. D. Slap the guest on the back several times.

Correct Answer is B

Explanation

Choice A rationale
Assisting the guest to the floor and beginning mouth-to-mouth resuscitation is not the appropriate initial response. The guest’s symptoms indicate choking, and the Heimlich maneuver is the recommended first aid response.
Choice B rationale

The Heimlich maneuver is the correct response when someone is choking. The guest’s symptoms of a weak cough, inability to speak, and grasping the throat are classic signs of choking.
Choice C rationale
Observing the guest before taking further action is not appropriate in this situation. Immediate action is required to clear the guest’s airway.
Choice D rationale
Slapping the guest on the back is not the recommended response for choking in adults. It can potentially cause the object to become more deeply lodged in the throat.

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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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