The nurse observes a student nurse administer a tuberculin skin test using the intradermal route. The nurse intervenes when the student performs which action?

Question

The nurse observes a student nurse administer a tuberculin skin test using the intradermal route.  The nurse intervenes when the student performs which action?

Quizplus · Accepted Answer

11ecbb05_cb33_2512_b433_819b8ea80f5c_MD0009_00 Intradermal dermal injections deliver a small amount of medication (0.1 mL) into the dermal layer of the skin, just under the epidermis. This parenteral route is used to perform allergy testing and tuberculosis (TB) screening. The correct procedure for administering a TB intradermal injection is as follows: Choose a1 mLtuberculin syringe with a27-gauge 1/4 inch needle then don clean gloves - the syringe is calibrated in hundredths of a millimeter and the intradermal needle is short enough to remain in the dermis with length range of 1/4-5/8 inch (Option B). Position the left forearm to face upward, and cleanse site that is a hands width above the wrist - the left arm is commonly used for TB testing; the forearm has little hair and subcutaneous tissue and is readily accessible to observe a skin reaction. Place non-dominant hand 1 inch below the insertion site and pull skin downward so that it is taut - taut skin makes it easier to insert the needle and promotes comfort. Insert the needle almost parallel to skin at a 10-degree angle with bevel up - this is important as the medication can enter the subcutaneous tissue if the angle is >15 degrees (Option D). Advance the tip of the needle through epidermis into dermis; outline of bevel should be visible under the skin - verify that the medication will be injected into dermis (Option A). Inject medication slowly while raising a small wheal (bleb) on the skin - verify that the medication is being deposited into the dermis (Option C). Remove needle and do not rub the area - rubbing promotes leakage through the insertion site and medication deposition into the tissue. Circle the area with a pen to assess for redness and induration (according to institution policy) - this delineates the border for measurement of reaction. Educational objective: For TB skin testing: Use a 27-gauge 1/4 inch needle with a 1 mL tuberculin syringe Administer injection on inner forearm at a 10-degree angle with bevel up Make a wheal (bleb) Avoid rubbing site after injection

The Nurse Observes a Student Nurse Administer a Tuberculin Skin