A nurse is preparing to administer an intradermal tuberculin test to a client. Which of the following actions should the nurse take?
Advance the needle 6 mm (7 in) below the skin's surface.
Point the bevel of the needle upward prior to insertion.
Administer the injection on the dorsal forearm.
Insert the needle at a 20° angle to the client's skin.
The Correct Answer is B
A. Advance the needle 6 mm (7 in) below the skin's surface: Intradermal injections should be administered just beneath the skin, not deeply. The needle should be inserted at an angle to form a small bleb just below the epidermis. This depth ensures proper absorption.
B. Point the bevel of the needle upward prior to insertion: The bevel should be facing upward when performing an intradermal injection to ensure the medication is injected just below the skin surface. This positioning helps form a visible wheal or bleb, which is necessary for the tuberculin test.
C. Administer the injection on the dorsal forearm: The recommended site for an intradermal tuberculin test is the inner aspect of the forearm, not the dorsal forearm. The inner forearm provides a flatter surface for easy visualization of the wheal.
D. Insert the needle at a 20° angle to the client's skin: An intradermal injection should be administered at a 5-15° angle to ensure the needle is positioned just beneath the skin’s surface. A 20° angle may result in the injection being too deep.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notify the primary care provider: Notifying the provider is important, but first, the nurse should assess the client’s condition by obtaining vital signs. This helps determine if immediate intervention is needed, like administering antidotes or treatments.
B. Obtain the client's vital signs: The first step is assessing the client’s physical status by checking vital signs. This helps identify signs of toxicity or immediate adverse effects from the overdose, guiding further actions.
C. Educate the client about potential adverse effects: Education is important, but it’s not the first priority in the case of an overdose. The nurse should first focus on assessing and stabilizing the client before providing information on potential adverse effects.
D. Complete an incident report: While an incident report is necessary, it is not the immediate priority. The nurse must first ensure the client’s safety and health by assessing and managing the overdose.
Correct Answer is A
Explanation
A. Double-bag the linens: When a client is on contact precautions, it is necessary to place soiled linens in a sealed bag to prevent contamination. Double-bagging the linens ensures that the exterior bag does not become contaminated and that the linens are securely contained.
B. Rinse the linens prior to removing them from the client's room: Rinsing the linens is not required when removing soiled linens. The main concern is preventing contamination, and double-bagging ensures that the linens are safely contained.
C. Tie the linens' bag securely at the top: While it is important to securely close the bag, double-bagging is the key step in preventing contamination. Tying the bag is part of the process, but it is not the primary focus for contact precautions.
D. Wear sterile gloves when handling the linens: Sterile gloves are not necessary for handling soiled linens in contact precautions. Clean gloves are sufficient to handle linens. Sterile gloves are typically used for invasive procedures, not for routine linen handling.
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