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 B

Explanation

Choice A reason: While fitting for an N95 mask is important, it is not required for droplet precautions, which are appropriate for meningococcal infections.

Choice B reason: For meningococcal infections, droplet precautions, including a standard face mask, are recommended for the first 24 hours of antimicrobial therapy.

Choice C reason: It is the responsibility of the healthcare facility to ensure that all staff members who require it are fitted for particulate filter masks, but this does not apply to droplet precautions for meningococcal infections.

Choice D reason: Sending the UAP for an immediate fitting for a particulate filter mask is unnecessary for droplet precautions and could delay essential care for the client.

A. Record the client's pulse rate and rhythm. B. Assist the client to stand at the bedside. C. Apply the blood pressure cuff securely. D. Position the client supine for a few minutes.

Correct Answer is D

Explanation

Choice A reason: Recording the client's pulse rate and rhythm is part of the assessment, but it is not the first action to take when assessing for orthostatic hypotension.
Choice B reason: Assisting the client to stand is part of the assessment process, but it should be done after the initial blood pressure and pulse have been measured while the client is supine.
Choice C reason: Applying the blood pressure cuff securely is necessary for an accurate reading, but it is not the first step in the process of assessing for orthostatic hypotension.
Choice D reason: The first action is to position the client supine for a few minutes before taking the initial blood pressure and pulse measurements, as this provides a baseline for comparison when the client stands.

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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

An unlicensed assistive personnel (UAP) assigned to feed a client with meningococcal infection, for whom droplet precautions have been implemented, requests a change in assignment, reporting they have not yet been fitted for an N95 respirator mask. Which action should the nurse take?

Correct Answer is B

Explanation

When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

Correct Answer is D

Explanation

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