The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?
Massage the site gently after injection.
Ensure bevel of the needle is pointing up.
Hold the syringe perpendicular to the skin.
Select upper arm as the injection site.
The Correct Answer is B
B. The needle should be inserted with the bevel facing up (visible through the skin). The goal is to deposit the medication into the epidermal layer (not subcutaneous tissue).
A. Massaging the site after injection can cause the medication to spread beyond the intended area, leading to inaccurate results or potential complications.
C. The correct angle for an intradermal injection is 5 to 15-degree angle. This angle allows for proper placement of the medication just below the epidermis.
D. Intradermal injections are usually administered on the forearm or the upper back, where the skin is thin and easily lifted to create a wheal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Allowing a period of rest before feeding is not a standard practice for individuals at risk for aspiration and may not address the underlying issues related to dysphagia or aspiration risk. A, C, D- are appropriate positions during feeding for clients with stroke to prevent choking/aspiration.
Correct Answer is D
Explanation
D. The most appropriate action for the nurse to take is to gather more information about the client's exercise schedule. This will help the nurse assess whether the client's exercise regimen may be contributing to or exacerbating the insomnia. Understanding the timing, intensity, and duration of the client's aerobic workouts can provide insights into potential factors affecting sleep patterns.
A. Advising the client that lifestyle changes often take several weeks to be effective is a valid point. However, it does not directly address the potential impact of exercise timing on sleep.
B. Determining the amount of weight the client has lost since increasing activity may provide useful information about the client's progress with weight loss but does not directly address the issue of difficulty falling asleep.
C. Encouraging the client to exercise every day to eliminate bedtime wakefulness is not necessarily appropriate, as excessive or late-night exercise may exacerbate rather than alleviate bedtime wakefulness in some individuals.
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