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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Printing the EMR from a backup server does not resolve the immediate issue of the system lockup and may not be possible if the system is down.
Choice B reason: Identifying information as a late entry is a step to take after the system issue has been resolved and does not address the current problem.
Choice C reason: Waiting for the system to be rebooted is passive and does not actively contribute to resolving the system lockup.
Choice D reason: Notifying the information services department is the first and most proactive step to take, as they are responsible for resolving technical issues with the EMR system.
Correct Answer is B
Explanation
Choice A reason: Praising the UAP for using standard precautions is not appropriate in this situation as using the same gloves for multiple clients breaches infection control protocols.
Choice B reason: The nurse should instruct the UAP to change gloves immediately to prevent cross-contamination between clients.
Choice C reason: While scheduling an in-service program on asepsis is beneficial for long-term education, it does not address the immediate risk of infection.
Choice D reason: Submitting an adverse occurrence report may be necessary if there is a pattern of non-compliance, but the first action should be to correct the behavior and ensure client safety.
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