You can be sure you have administered the intradermal injection properly if which occurs?
There is no pain at the site.
There is immediate blood return at the site.
The skin remains flat and turns red at the injection site.
A bleb or wheal occurs immediately.
The Correct Answer is D
Choice A rationale
Absence of pain at the site of an intradermal injection does not confirm proper administration. While minimizing pain is a goal, the primary indicator of correct intradermal placement is the formation of a bleb, which signifies the medication has been correctly deposited within the dermal layer, not subcutaneously.
Choice B rationale
Immediate blood return at the site of an intradermal injection indicates improper technique, specifically penetration into a blood vessel. Intradermal injections are administered into the avascular dermal layer; therefore, aspiration should yield no blood, and blood return necessitates withdrawing and restarting the injection at a new site.
Choice C rationale
Skin remaining flat and turning red at the injection site is not indicative of proper intradermal injection. Redness may occur due to irritation, but a flat appearance suggests the medication was either injected too deeply into the subcutaneous tissue or insufficient volume was administered into the dermal layer to form a bleb.
Choice D rationale
The immediate formation of a bleb or wheal, resembling a small blister, is the definitive sign of a correctly administered intradermal injection. This occurs because the medication is deposited precisely into the superficial dermal layer of the skin, causing a localized elevation as the fluid displaces tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Pulling the lobe up and back is the correct technique for administering ear drops to adults and children older than three years of age. This maneuver straightens the ear canal in older individuals due to the anatomical development and orientation of the Eustachian tube and external auditory meatus.
Choice B rationale
Instructing parents to hold the child upright for 10 minutes is an appropriate post-administration instruction to facilitate medication absorption and prevent spillage. However, this action is not part of the physical technique for correctly preparing the ear canal for drop instillation.
Choice C rationale
For children under 3 years old, the external auditory canal is straighter and angled differently than in adults. Pulling the pinna down and back straightens this shorter, more upwardly curved canal, allowing the medication to flow more effectively and reach the tympanic membrane for optimal absorption.
Choice D rationale
Massaging the tragus after instillation helps to distribute the medication throughout the ear canal and facilitate its passage deeper. However, massaging the tragus before administering the drops does not contribute to straightening the ear canal and is not a preparatory step for instillation.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
The aortic valve, located between the left ventricle and the aorta, is best auscultated at the second intercostal space (ICS) along the right sternal border. This anatomical landmark allows for optimal sound transmission as blood is ejected from the left ventricle into the systemic circulation, enabling clear identification of S2 heart sounds and potential aortic murmurs.
Choice B rationale
The pulmonic valve, positioned between the right ventricle and the pulmonary artery, is most clearly heard at the second intercostal space (ICS) along the left sternal border. This specific location facilitates the detection of sounds associated with blood flow from the right ventricle into the pulmonary circulation, aiding in the assessment of right heart function and conditions like pulmonary hypertension.
Choice C rationale
The tricuspid valve, situated between the right atrium and the right ventricle, is best auscultated at the fourth intercostal space (ICS) along the left sternal border. This site is optimal for assessing the flow of deoxygenated blood into the right ventricle, allowing for the detection of murmurs related to tricuspid regurgitation or stenosis, and evaluating right heart filling.
Choice D rationale
The mitral valve, located between the left atrium and the left ventricle, is most accurately assessed at the fifth intercostal space (ICS) at the left midclavicular line (MCL). This apex beat location is crucial for hearing sounds associated with the filling of the left ventricle and detecting murmurs indicative of mitral valve prolapse, regurgitation, or stenosis, reflecting left heart function.
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