which techniques should the nurse use to administer an intradermal id injection for a mantoux test to screen for tuberculosis tb select all that apply
Logo

Nursing Elites

HESI LPN

HESI CAT Exam

1. Which techniques should be used to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB)? Select all that apply.

Correct answer: A

Rationale: Observing for an intradermal bleed after the antigen is injected is a proper technique for an ID injection. This is important to confirm the correct placement of the injection. Choice B is correct because the recommended site for an ID injection for a Mantoux test is the volar surface of the forearm. Choice C is incorrect because the standard needle size for an ID injection is usually 26 or 27 gauge with a length of 1/4 to 5/8 inches, not 25 gauge with a length of 1/2 inch. Choice D is incorrect because the needle should be inserted into the skin with the bevel facing up, not down.

2. A nurse is preparing to administer an intramuscular (IM) injection to a client. What is the most appropriate site to use for an IM injection in an adult?

Correct answer: B

Rationale: The correct answer is B: Vastus lateralis muscle. The vastus lateralis muscle is a recommended site for IM injections in adults due to its size and accessibility. The dorsal gluteal muscle is not recommended for IM injections in adults due to the proximity to major nerves and blood vessels, increasing the risk of injury. The rectus femoris muscle is not a common site for IM injections in adults. The deltoid muscle is typically used for IM injections in small-volume medications or vaccines, especially in adults.

3. A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. What intervention should the nurse implement?

Correct answer: C

Rationale: In the scenario described, the client presents with signs of fluid overload and hyponatremia. Restricting oral fluid intake is the appropriate intervention to manage fluid overload and correct hyponatremia. Increasing the intake of salty foods (Choice A) and administering NaCl supplements (Choice B) would exacerbate the sodium imbalance. Holding the client's loop diuretic (Choice D) is not directly related to addressing the fluid overload and hyponatremia.

4. An older client is having photocoagulation for macular degeneration. What intervention should the nurse implement during post-procedure care in the outpatient surgical unit?

Correct answer: A

Rationale: The correct intervention is to apply bilateral eye patches while sleeping. This measure helps protect the eyes and support healing following photocoagulation for macular degeneration. Choice B is incorrect as using a whiteboard is not directly related to post-procedure care for this intervention. Choice C is incorrect as arranging food on the plate in a clockwise order is not relevant to the post-procedure care of photocoagulation. Choice D is incorrect as verbally identifying oneself when entering the room is important for communication but not specific to the post-procedure care in this scenario.

5. A client who sustained a pellet gun injury with a resulting comminuted skull fracture is admitted overnight for observation. Which assessment finding obtained two hours after admission necessitates immediate intervention?

Correct answer: B

Rationale: In a client with a pellet gun injury and a comminuted skull fracture, repeatedly falling asleep while talking with the nurse is a concerning sign. It can indicate increased intracranial pressure or a deteriorating condition, requiring immediate intervention. The other options, such as a throbbing headache (choice A), slow trickle of bright red blood at the entry site (choice C), or reddened and edematous entry site (choice D), while important to monitor, do not directly indicate a need for immediate intervention as much as the client falling asleep repeatedly while talking does.

Similar Questions

The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse?
A client with complaints of shortness of breath and abdominal pain 1 week after bariatric surgery is admitted for follow-up evaluation. Which assessment finding warrants immediate intervention by the nurse?
Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?
At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client’s electronic health record, which priority nursing action should the nurse implement?
When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses