A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

Document the site where the medication was given.

Notify the healthcare provider of the allergic response.

Elevate the area and apply light pressure over the site.

Apply a cold pack to the area for twenty minutes.

Answer and Explanation

The Correct Answer is A

Choice A reason: The appearance of a small, round raised area, known as a wheal, is a normal reaction to an intradermal injection and should be documented.

Choice B reason: This is not an allergic response but a normal reaction to an intradermal injection, so there is no need to notify the healthcare provider.

Choice C reason: There is no need to elevate the area or apply pressure as the raised area is a normal reaction to the medication being correctly placed in the dermis.

Choice D reason: Applying a cold pack is not necessary for a normal reaction to an intradermal injection.

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Correct Answer is C

Explanation

Choice A reason: Modifying nursing interventions is a step that may be necessary after evaluating the effectiveness of care, but it is not the immediate next action after reviewing the expected outcomes.

Choice B reason: Determining if the expected outcomes were realistic is part of the evaluation process, but it requires current data to make an informed decision.

Choice C reason: Obtaining current client data is essential to compare with the expected outcomes and determine if the goals of care are being met.

Choice D reason: Reviewing related professional standards of care is important for ensuring quality care, but it is not the direct next step in evaluating the effectiveness of the client's nursing care.

Correct Answer is ["0.8"]

Explanation

Amount (mg) ÷ Concentration (mg/mL) = Volume (mL)

Step 1: The amount of hydromorphone the patient needs is 3 mg. Step 2: The concentration of the hydromorphone solution is 4 mg/mL. Step 3: Substitute the values into the formula: 3 mg ÷ 4 mg/mL.

Step 4: Calculate the volume: 3 ÷ 4 = 0.75 mL. 0.8 rounded to the nearest tenth

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A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

Correct Answer is C

Explanation

Correct Answer is ["0.8"]

Explanation

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