The nurse is preparing to administer an intradermal injection.
Which angle should the nurse insert the needle?

15 degrees.

90 degrees.

45 degrees.

30 degrees.

Answer and Explanation

The Correct Answer is A

Choice A rationale

An intradermal injection is administered into the dermis, the layer of skin directly beneath the epidermis. A 15-degree angle ensures the needle enters superficially, creating a small wheal as the medication is deposited. This shallow angle minimizes penetration into subcutaneous tissue, which is crucial for proper antigen-antibody reactions in allergy testing or tuberculosis screening.

Choice B rationale

A 90-degree angle is used for intramuscular injections, where the medication is delivered deep into muscle tissue. This angle allows for rapid absorption due to the rich vascular supply of muscle, but it would cause excessive penetration and potential systemic absorption if used for an intradermal injection, negating its diagnostic purpose.

Choice C rationale

A 45-degree angle is typically used for subcutaneous injections, delivering medication into the adipose tissue layer beneath the dermis. This angle is too deep for an intradermal injection and would result in the medication being absorbed systemically rather than remaining in the dermal layer for localized diagnostic reactions.

Choice D rationale

A 30-degree angle is also too steep for an intradermal injection. While less deep than a 45-degree angle, it still risks penetrating beyond the dermis into the subcutaneous tissue. The goal of an intradermal injection is to deposit the substance within the highly specific dermal layer to elicit a localized, measurable response.

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Correct Answer is C

Explanation

Choice A rationale

"Right medication" refers to ensuring that the drug administered is precisely the one prescribed by the healthcare provider. This involves verifying the medication name, strength, and formulation against the order. In this scenario, the issue is not the medication itself, but rather the timing of its administration, making this choice incorrect.

Choice B rationale

"Right route" pertains to administering the medication via the prescribed pathway (e.g., oral, intravenous, subcutaneous). This ensures that the drug reaches the systemic circulation or target site effectively. The scenario explicitly states "oral guaifenesin," indicating the route was correct; the error lies in the timing.

Choice C rationale

"Right time" is a crucial aspect of medication administration, ensuring that the drug is given at the prescribed frequency and within the specified time window. Administering a medication 2 hours after its scheduled dose constitutes a deviation from the ordered time, potentially affecting its therapeutic efficacy or peak plasma concentration.

Choice D rationale

"Right dose" involves verifying that the amount of medication given is precisely what was ordered, preventing under-dosing or over-dosing. The scenario does not indicate any error in the quantity of guaifenesin administered, only the timing of its delivery. Therefore, this choice is not applicable to the described problem.

A. Turn the patient to the right side once medications have been administered. B. Leave patient in high-Fowler's position for 30 minutes after administering medication. C. Flush the tube with 10-15 mL of water after each medication. D. Hold the medication if 50 ml of residual is obtained.

Correct Answer is B

Explanation

Choice A rationale

Turning the patient to the right side immediately after medication administration via a tube is generally not recommended as it may promote rapid gastric emptying which can potentially lead to dumping syndrome or alter drug absorption by moving the medication out of the stomach too quickly.

Choice B rationale

Leaving the patient in a high-Fowler's position for 30 minutes after administering medications through a tube helps prevent aspiration by utilizing gravity to keep the medication in the stomach. This position also aids in proper digestion and absorption by maintaining gastrointestinal motility and reducing reflux.

Choice C rationale

Flushing the tube with 10-15 mL of water after each medication is generally insufficient to clear the tube effectively and prevent clogging, especially with viscous medications. A standard flush volume of 30-60 mL is typically recommended to ensure complete medication delivery and tube patency.

Choice D rationale

Holding medication if 50 mL of residual is obtained is not a universal standard. The acceptable residual volume varies based on institutional policy, patient condition, and the type of feeding. Often, a residual volume of 200-250 mL or more is the threshold for holding medications.

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The nurse is preparing to administer an intradermal injection. Which angle should the nurse insert the needle?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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The nurse is preparing to administer an intradermal injection.
Which angle should the nurse insert the needle?