A nurse is preparing to administer an intradermal injection for a tuberculin screening. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Insert the needle into the dermis layer of skin.

Inject the medication slowly with the skin pulled taut.

Cleanse the skin using a circular motion.

Produce a small wheal on the surface of the skin.

Hold the needle with the bevel facing up.

Answer and Explanation

The Correct Answer is C,E,A,B,D

C. Cleanse the skin using a circular motion: Cleaning the site first prevents infection and prepares the area for safe injection. Using a circular motion from the center outward helps remove microorganisms without contaminating the injection site.

E. Hold the needle with the bevel facing up: Positioning the needle bevel up ensures a smoother entry into the dermis and reduces tissue trauma, which is important for accurate intradermal administration.

A. Insert the needle into the dermis layer of skin: The needle is inserted at a very shallow angle into the dermis. Proper placement is essential for the tuberculin test to produce a valid reaction.

B. Inject the medication slowly with the skin pulled taut: Slowly injecting the medication ensures it remains in the dermis and prevents leakage into subcutaneous tissue. Pulling the skin taut stabilizes the area and allows for precise administration.

D. Produce a small wheal on the surface of the skin: The appearance of a small, raised wheal confirms that the medication has been correctly administered intradermally. This wheal is necessary for the subsequent reading of the tuberculin test.

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Correct Answer is C

Explanation

A. Decreased white blood cells: Erythropoietin specifically stimulates red blood cell production in the bone marrow. White blood cell counts are not directly affected by this medication, so a decrease would not indicate effectiveness.

B. Increased calcium: Calcium levels are unrelated to erythropoietin therapy. Changes in calcium do not reflect the medication’s ability to stimulate erythropoiesis.

C. Increased hemoglobin: Erythropoietin promotes red blood cell production, which increases hemoglobin and hematocrit levels. An elevation in hemoglobin indicates the medication is effectively stimulating erythropoiesis.

D. Decreased BUN: Blood urea nitrogen reflects kidney function and protein metabolism. While erythropoietin is often used in clients with chronic kidney disease, a decrease in BUN is not a direct measure of the drug’s effectiveness.

A. Document the updated list and send it to the pharmaсу. B. Compare preadmission medications to current medications. C. Address any discrepancies between current medications and new prescriptions. D. Compile a list of all medications the client is currently taking.

Correct Answer is D

Explanation

A. Document the updated list and send it to the pharmacy: Documentation occurs after all medications have been reviewed and discrepancies resolved. Completing this step first could result in incomple te or inaccurate records.

B. Compare preadmission medications to current medications: Comparison is done after compiling a comprehensive list of current medications. Without knowing exactly what the client is taking, discrepancies cannot be identified.

C. Address any discrepancies between current medications and new prescriptions: Resolving discrepancies comes after compiling and comparing medication lists. This ensures that interventions are based on accurate and complete information.

D. Compile a list of all medications the client is currently taking: The first step in medication reconciliation is gathering a complete and accurate list of all medications, including prescriptions, over-the-counter drugs, and supplements. This forms the foundation for safe comparison and management.

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A nurse is preparing to administer an intradermal injection for a tuberculin screening. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory findings of a client who is taking erythropoietin. Which of the following results indicates the medication is effective?

Correct Answer is C

Explanation

A nurse is caring for a client and preparing to complete a medication reconciliation. Which of the following actions should the nurse complete first?

Correct Answer is D

Explanation

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