After administering an intradermal (ID) injection for a skin test, the nurse notices a small bleb at the injection site. Which of these is the best action for the nurse to take at this time?
Do nothing
Report the bleb to the physician.
Massage the area
Apply heat
The Correct Answer is A
A. It is expected and should be observed for reaction

B. Reporting is not necessary as it is expected
C, D. Massaging the area or applying heat interferes with the test results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. vancomycin can be nephrotoxic and fluid restriction is inappropriate
B. Slow infusion of vancomycin is key to avoid flush reactions
C. Normal trough levels for vancomycin are 10-20mcg/ml- 24mcg/ml increases risk of toxicity
D. Monitoring serum creatinine monitors for renal damage
E. Vancomycin can cause hearing loss and clients should be advised any early signs of ototoxicitysuch as ear fullness
Correct Answer is D
Explanation
D. Fluid retention due to leakage of fluid leads to increase in weight
A. Capillary leak syndrome leads wet cough
B. Capillary leak syndrome leads to flushing but not bruising of the skin
C. leads to tachycardia due to reduced effective volume
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