The nurse is instructing a nursing student in proper technique for an intradermal injection. Which does the nurse use to evaluate proper technique for a tuberculin skin test after injecting the solu-tion?
a. The nurse palpates a deep, firm pocket of the test solution.
b. The nurse observes a nearly clear bubble slightly under the skin.
c. A small trickle of blood appears at the puncture site within minutes.
d. A 2-cm (3/4-inch) pink, flattened area develops at the injection site within 1 hour.
B
The nurse observes a small bubble (bleb) just under the surface of the skin on needle withdrawal after a properly administered tuberculin skin test; an intradermal injection deposits medication below the skin but above subcutaneous tissue. The wheal is practically clear, denoting that the medication is in an avascular area. The pocket of test solution is relatively soft and superficial. Blood should not trickle from the injection site; if it does, the injection is potentially too deep. Within 1 hour, most intradermal tests are completely absorbed unless the patient has a reaction to the fluid, as with allergy testing or a positive tuberculin skin test.
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