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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?
- A. Apply heat.
- B. Massage the area.
- C. Do nothing.
- D. Report the bleb to the physician.
Correct Answer: C
Rationale: A small bleb is an expected outcome after an intradermal injection for skin testing, indicating proper administration. No further action is needed.
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The nurse needs to administer insulin subcutaneously to an obese patient. Which is the proper technique for this injection?
- A. Using the Z-track method
- B. Inserting the needle at a 5- to 15-degree angle until resistance is felt
- C. Pinching the skin at the injection site, and then inserting the needle to below the tissue fold at a 90-degree angle
- D. Spreading the skin tightly over the injection site, inserting the needle, and then releasing the skin
Correct Answer: C
Rationale: For subcutaneous injections in obese patients, pinching the skin and inserting the needle at a 90-degree angle ensures delivery into the subcutaneous tissue. The Z-track method is for IM injections, a 5- to 15-degree angle is incorrect, and spreading the skin is not appropriate for subcutaneous administration.
A 2-year-old child is to receive ear drops. The nurse is teaching the parent about giving the ear drops. Which instruction is appropriate?
- A. Administer the drops without pulling on the ear lobe.
- B. Straighten the ear canal by pulling the lobe upward and back.
- C. Straighten the ear canal by pulling the pinna down and back.
- D. Straighten the ear canal by pulling the pinna upward and outward.
Correct Answer: C
Rationale: For children under 3 years, pulling the pinna down and back straightens the ear canal for proper ear drop administration. The other methods are incorrect for this age group.
The nurse is preparing to give an aqueous intramuscular (IM) injection to an average-sized adult. Which actions are appropriate? (Select all that apply.)
- A. Choose a 26- or 27-gauge, 1/4 to 1/2-inch needle.
- B. Choose a 20- to 25-gauge, 1- to 1 1/2-inch needle.
- C. Choose the dorsogluteal site, the preferred site for IM injections for adults.
- D. Insert the needle at a 45-degree angle.
- E. Insert the needle at a 90-degree angle.
- F. Before injecting the medication, withdraw the plunger to check for blood return.
Correct Answer: B,E,F
Rationale: For IM injections in adults, use a 20- to 25-gauge, 1- to 1 1/2-inch needle, insert at a 90-degree angle, and check for blood return to avoid intravascular injection. The dorsogluteal site is not preferred due to nerve risks; the ventrogluteal site is recommended. A 26- or 27-gauge needle is too small, and a 45-degree angle is for subcutaneous injections.
A patient is receiving eyedrops that contain a beta-blocker medication. The nurse will use what method to reduce systemic effects after administering the eyedrops?
- A. Wiping off excess liquid immediately after instilling the drops
- B. Having the patient close the eye tightly after the drops are instilled
- C. Having the patient try to keep the eye open for 30 seconds after the drops are instilled
- D. Applying gentle pressure to the patient's nasolacrimal duct for 30 to 60 seconds after instilling the drops
Correct Answer: D
Rationale: Applying gentle pressure to the nasolacrimal duct for 30-60 seconds reduces systemic absorption of eyedrops by preventing drainage into the nasal cavity. The other methods do not effectively reduce systemic effects.
The nurse will plan to use the Z-track method of intramuscular (IM) injections for which situation?
- A. The medication is known to be irritating to tissues.
- B. The patient is emaciated and has very little muscle mass.
- C. The medication must be absorbed quickly into the tissues.
- D. The patient is obese and has a deep fat layer below the muscle mass.
Correct Answer: A
Rationale: The Z-track method is used for medications that irritate tissues or cause staining, preventing leakage into subcutaneous tissues. It is not specifically for emaciated or obese patients or for rapid absorption.