SKills 22- administration of parenteral meds

6. The nurse is preparing to give an intramuscular injection to a toddler. To decrease pain, a eutectic mixture of local anesthetics (EMLA) cream is applied to the injection site at least ______ hour(s) before administration of the injection.

ANS: 1 Eutectic mixture of local anesthetics (EMLA) cream should be applied to the injection site at least 1 hour before IM injection to decrease pain. DIF: Cognitive Level: Applying REF: Text reference: p. 576 OBJ: Discuss ways to promote patient comfort while administering an injection. TOP: Pediatric Considerations for Intramuscular Injections KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

COMPLETION 1. The health care provider orders 4 units of regular insulin and 10 units of NPH insulin subcutaneous before breakfast. The nurse draws the regular insulin into the syringe and is preparing to draw the NPH insulin into the same syringe. When finished, the syringe should contain _________ units.

ANS: 14 The combined units of insulin are determined by adding the number of units of both insulins together (4 units of regular + 10 units of NPH = 14 units). DIF: Cognitive Level: Applying REF: Text reference: p. 586 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Subcutaneous Insulin Injection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

9. The nurse is preparing to draw up a medication using a filter needle and a syringe. This equipment is necessary when the medication is being withdrawn from an ______________.

ANS: ampule Filter needles must be used when medication is withdrawn from a glass ampule. Filter needles prevent glass particles from being drawn into the syringe. DIF: Cognitive Level: Understanding REF: Text reference: p. 576 OBJ: Correctly prepare injectable medications from a vial and an ampule. TOP: Filter Needle KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

4. The patient is receiving allergy testing. The nurse is using the inner forearm to inject the allergen into the ____________.

ANS: dermis Intradermal (ID) injections are used for allergy testing. They are injected into the dermis, usually in the inner forearm or upper back. DIF: Cognitive Level: Applying REF: Text reference: p. 589 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Intradermal (ID) Injection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

11. While checking the patient's intravenous (IV) site, the nurse notices that the site is cool, pale, and swollen. She immediately stops the IV infusion, realizing that these are signs indicating _____________.

ANS: infiltration The patient has an unexpected outcome when his intravenous site becomes cool, pale, and swollen, indicating infiltration. DIF: Cognitive Level: Analyzing REF: Text reference: p. 612 OBJ: Evaluate the effectiveness and outcomes of administering medications by each injection route. TOP: Infiltration KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

3. The nurse informs the patient that the medication will be absorbed rapidly because it was injected into tissue with a rich blood supply. The patient has just received a ______________ injection.

ANS: intramuscular (IM) intramuscular The intramuscular (IM) injection route deposits medication into deep muscle tissue, which has a rich blood supply, allowing the medication to be absorbed faster than by the subcutaneous or intradermal route. DIF: Cognitive Level: Applying REF: Text reference: p. 593 OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP: Intramuscular (IM) Injection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. A patient with multiple intravenous lines has blood infusing in the right antecubital space, parenteral nutrition infusing through a right subclavian line, and normal saline with potassium infusing in the left forearm. An intravenous medication is ordered stat. The nurse will use the line in the ____________ to administer the medication.

ANS: left forearm Never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions. DIF: Cognitive Level: Applying REF: Text reference: p. 614 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Intravenous (IV) Injection or Infusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

10. The patient is complaining of tenderness at his intravenous (IV) insertion site. The nurse examines the site and notices that the site is swollen, warm, and reddened. The nurse stops the intravenous infusion, realizing that the patient has ________________.

ANS: phlebitis The patient has an unexpected outcome when his intravenous site becomes swollen, warm, reddened, and tender to touch, indicating phlebitis. DIF: Cognitive Level: Analyzing REF: Text reference: p. 608-609 OBJ: Evaluate the effectiveness and outcomes of administering medications by each injection route. TOP: Phlebitis KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

7. The most frequent route of exposure to bloodborne disease for health care workers is needlestick injury. The nurse recognizes that implementation of _________________ can prevent needlestick injury.

ANS: safe needle devices The Needlestick Safety and Prevention Act is a federal law that mandates health care facilities to use safe needle devices to reduce the frequency of needlestick injury. DIF: Cognitive Level: Understanding REF: Text reference: p. 577 OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP: Needlestick Injuries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

8. An experienced nurse recognizes that the dorsogluteal injection site is no longer used for intramuscular injections because of the risk of damaging the _______________.

ANS: sciatic nerve Recent evidence supports avoiding the traditional dorsogluteal route in favor of the ventrogluteal site. Therefore, the dorsogluteal site should not be used as a site for IM injection. Studies have demonstrated that the exact location of the sciatic nerve varies from one person to another. If a needle hits the sciatic nerve, the patient may experience permanent or partial paralysis of the involved leg. DIF: Cognitive Level: Understanding REF: Text reference: p. 601 OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP: Complications of IM Injections KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

2. The nurse injects the medication into the loose connective tissue just under the dermis when giving a _____________ injection.

ANS: subcutaneous A subcutaneous injection involves depositing medication into the loose connective tissue underlying the dermis. DIF: Cognitive Level: Remembering REF: Text reference: p. 593 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Subcutaneous Injection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

3. The nurse is administering a parenteral medication to the patient. Which action by the nurse demonstrates proper technique? a. Using strict aseptic technique b. Using work-arounds to administer medications in a timely manner c. Injecting the medication smoothly but rapidly d. Inserting the needle into the patient's skin smoothly and slowly

ANS: A Strict aseptic technique is used during all steps of preparation and administration of parenteral medications. Work-arounds bypass a procedure, policy, or protocol and should not be used. Medication should be injected slowly and smoothly. The needle should be inserted smoothly and quickly. DIF: Cognitive Level: Applying REF: Text reference: p. 576 OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP: Aseptic Technique in Injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

20. The nurse is preparing to administer a medication using a volume-controlled administration set or Volutrol. Which action should the nurse do first? a. Open the clamp between the Volutrol and the main intravenous (IV) bag. b. Open the air vent on the Volutrol. c. Inject the medication into the Volutrol. d. Clean the injection port on top of the Volutrol.

ANS: A The Volutrol is filled with the desired amount of intravenous (IV) fluid (50 to 100 mL) by opening the clamp between the Volutrol and the main IV bag. After the Volutrol is filled with the desired amount of fluid, the clamp is closed and the clamp on the air vent of the Volutrol is checked and opened if necessary. The injection port on the Volutrol is cleaned, and the medication is injected through the port. DIF: Cognitive Level: Applying REF: Text reference: p. 614 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Volume-Control Administration Sets KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

14. A student nurse is preparing to administer an intramuscular injection into the ventrogluteal muscle. The nursing instructor should question which action by the student? a. Asking the patient to assume a sitting position b. Placing the heel of the hand over the patient's greater trochanter c. Asking the patient to flex the knee and hip d. Using the right hand to locate the injection site on the patient's left side

ANS: A The patient should lie in either the supine or the lateral position while the ventrogluteal muscle is located. To locate the ventrogluteal site, the heel of the hand is placed over the greater trochanter of the patient's hip with the wrist almost perpendicular to the femur. The right hand is used for the left hip, and the left hand is used for the right hip. To relax the muscle, the patient lies on the side or back with the knee and hip flexed. DIF: Cognitive Level: Applying REF: Text reference: p. 601 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Ventrogluteal Injection Site KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

18. A patient with a continuous IV infusion has an order for ciprofloxacin to be given IV piggyback. Which action by the nurse is appropriate for administering the medication? a. Hang the bag with ciprofloxacin higher than the continuous infusion bag. b. Stop the continuous infusion while running the ciprofloxacin. c. Connect the piggyback tubing into the Y-port on the tubing of the continuous infusion that is closest to the patient. d. Occlude the tubing of the continuous infusion just above the injection port while injecting the medication.

ANS: A The set is called a "piggyback" because the small bag or bottle is set higher than the primary infusion bag or bottle. In the piggyback setup, the main line does not infuse when a compatible piggybacked medication is infusing. The port of the primary IV line contains a back-check valve that automatically stops the flow of the primary infusion once the piggyback infusion flows. After the piggyback solution infuses and the solution within the tubing falls below the level of the primary infusion drip chamber, the back-check valve opens, and the primary infusion starts to flow again. The piggyback is connected to a short tubing line that connects to the upper Y-port of a primary infusion line or to an intermittent venous access. The tubing is occluded to check for blood return or to give an IV bolus, but not for a piggyback medication. DIF: Cognitive Level: Applying REF: Text reference: p. 614 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Piggyback Infusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

Chapter 22: Administration of Parenteral Medications Perry et al.: Clinical Nursing Skills & Techniques, 9th Edition MULTIPLE CHOICE 1. The nurse is preparing an injection of 0.45 mL of medication for a pediatric patient. Which syringe is most appropriate? a. Tuberculin syringe b. Insulin syringe c. 3-mL syringe d. 10-mL syringe

ANS: A The tuberculin syringe is calibrated in hundredths of a milliliter and has a capacity of 1 mL. It is used to prepare small amounts of medication such as small, precise doses for infants or young children. It is also used for intradermal and subcutaneous injections. An insulin syringe is used to administer insulin and is calibrated in units. A 3-mL syringe and a 10-mL syringe are calibrated in 0.2 of a milliliter and are not accurate for small volumes. DIF: Cognitive Level: Applying REF: Text reference: p. 578 OBJ: Explain the importance of selecting the proper size syringe and needle for an injection. TOP: Syringes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

15. The nurse is preparing to administer an immunization to a toddler. Which action by the nurse is appropriate? a. Grasp the body of the muscle during injection. b. Place one hand above the knee and one below the knee to find the site. c. Have the patient's knee flexed with the foot internally rotated. d. Ask the mother to hold the toddler on his side.

ANS: A The vastus lateralis is the preferred injection site for administration of immunizations to infants, toddlers, and children. With young children, it helps to grasp the body of the muscle during injection to be sure the medication is deposited in muscle tissue. The muscle is located on the anterior lateral aspect of the thigh. In an adult, one hand is placed above the knee and one below the greater trochanter to locate the muscle. To relax the muscle, the patient lies flat with the knee slightly flexed and the foot externally rotated or assumes a sitting position. A side-lying position would not be appropriate for this immunization. DIF: Cognitive Level: Applying REF: Text reference: p. 601 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Vastus Lateralis Injection Site KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

5. The nurse is teaching a patient how to mix 5 units of regular insulin and 15 units of NPH insulin in the same syringe. The nurse determines that further instruction is needed if the patient does which of the following? a. Injects 5 units of air into the regular insulin vial first and withdraws 5 units of regular insulin. b. Injects 15 units of air into the NPH insulin vial but does not withdraw the medication. c. Withdraws 5 units of regular insulin before withdrawing 15 units of NPH insulin. d. Calculates the combined total insulin dose as 20 units after withdrawing the regular insulin from the vial.

ANS: A When rapid- or short-acting insulin is mixed with intermediate- or long-acting insulin, air should be injected into the intermediate- or long-acting insulin vial first without withdrawal of the medication. Regular insulin is withdrawn first, and then the combined total insulin dose is calculated before the NPH insulin is withdrawn from the vial. DIF: Cognitive Level: Applying REF: Text reference: p. 588 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Mixing Insulin KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

6. The nurse is preparing to administer an intravenous (IV) medication that must be diluted in 60 mL of fluid and then given over 45 minutes. Which of the following methods can the nurse use to give this medication? (Select all that apply.) a. Piggyback infusion b. Volume-control device c. Mini-infusion pump d. IV bolus injection

ANS: A, B, C Piggyback infusions contain 25 to 250 mL, volume-control devices contain 50 to 150 mL, and mini-infusion pumps contain 5 to 60 mL. All three can be set to deliver the medication over a specific time frame. IV bolus injections are smaller volumes that are delivered quickly, usually over a few minutes. DIF: Cognitive Level: Applying REF: Text reference: p. 614 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Administration of IV Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

2. The nurse is preparing to administer an intramuscular medication. In determining which size needle and syringe to use to administer the medication, the nurse must consider which of the following? (Select all that apply.) a. The volume of medication b. The viscosity of the medication c. The size and weight of the patient d. Whether or not the syringe has a safety needle

ANS: A, B, C The nurse needs to determine the appropriate size of syringe and needle to be used. The smallest syringe possible for the volume of medication should be used to improve the accuracy of medication preparation. The needle length is chosen by the patient's size and weight, the type of tissue to be injected, and the route of administration. The needle gauge is determined by the viscosity of the medication. DIF: Cognitive Level: Applying REF: Text reference: p. 601 OBJ: Explain the importance of selecting the proper size syringe and needle for an injection. TOP: Choosing Correct Syringe and Needle Size KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. The nurse follows practice guidelines when administering injections to a patient to avoid which possible complications? (Select all that apply.) a. Drug response that is too rapid or too slow b. Nerve injury with possible pain or paralysis c. Death of tissue surrounding the injection site d. Death of the patient

ANS: A, B, C, D Failure to inject a medication correctly will result in complications such as an inappropriate drug response (e.g., too rapid and too slow), nerve injury with associated pain or paralysis, localized bleeding, tissue necrosis, and sterile abscess. Administration of an IV push medication too quickly can cause death. DIF: Cognitive Level: Understanding REF: Text reference: p. 576 OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP: Choosing Correct Injection Method KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

3. The nurse is preparing a subcutaneous injection for a patient. The nurse is careful not to touch which part of the syringe or needle? (Select all that apply.) a. The needle hub b. The needle shaft c. The syringe outer barrel d. The needle bevel

ANS: A, B, D The needle hub, shaft, and bevel must remain sterile at all times. DIF: Cognitive Level: Applying REF: Text reference: p. 579 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Maintaining Needle Sterility KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

12. The nurse is preparing an intramuscular injection for a thin elderly patient. The nurse is aware that the maximum volume most likely tolerated by this patient is which amount? a. 1 mL b. 2 mL c. 3 mL d. 5 mL

ANS: B Elderly adults and thin patients often tolerate only 2 mL in a single injection. A normal, well-developed adult can safely tolerate 2 to 5 mL of medication in larger muscles such as the ventrogluteal. However, clinically, it is unusual to administer more than 3 mL of medication in a single injection because the body does not absorb it well. DIF: Cognitive Level: Applying REF: Text reference: p. 601 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Volume of Medication That Can Be Given Safely IM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

13. The nurse is preparing to administer an intramuscular injection via the Z-track method. Which action should be taken by the nurse? a. Pinch the skin between the thumb and the first finger. b. Insert the needle at a 90-degree angle. c. Immediately remove the needle after injecting the medication. d. Release the skin before removing the needle from the site.

ANS: B For an intramuscular injection, the needle is inserted perpendicular to the patient's body as close to 90 degrees as possible. In using the Z-track method, the overlying skin and subcutaneous tissues are pulled approximately 2.5 to 3.5 cm (1 to inches) laterally to the side with the ulnar side of the nondominant hand. Keep the needle inserted for 10 seconds after injection to allow the medication to disperse evenly. Release the skin after withdrawing the needle. DIF: Cognitive Level: Applying REF: Text reference: p. 601 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Z-Track Method KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

17. The nurse is preparing to give a medication by intravenous (IV) bolus. When assessing the patient's IV insertion site, the nurse notes that it is warm, reddened, and tender. What action should the nurse take first? a. Slow the infusion rate and slowly inject the medication. b. Discontinue the IV infusion. c. Inject a local anesthetic to relieve the tenderness. d. Apply warm compresses over the insertion site.

ANS: B Swelling, warmth, redness, and tenderness indicate infiltration or phlebitis. Stop the IV infusion, remove the IV catheter, treat the IV site as indicated by institutional policy, and insert a new IV catheter if therapy continues. DIF: Cognitive Level: Applying REF: Text reference: p. 607-609 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Phlebitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

7. The nurse is preparing several medications that are administered parenterally. The patient receiving which medication will have an intradermal injection? a. Opioid b. Medication for allergy testing c. Low-molecular-weight heparin d. Glargine insulin

ANS: B The nurse typically gives intradermal injections for skin testing, for example, in tuberculin screening and allergy tests. Opioid pain medications, low-molecular-weight heparin, and insulin are administered subcutaneously, not intradermally. DIF: Cognitive Level: Applying REF: Text reference: p. 589 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Intradermal Injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

21. The student nurse is preparing to administer an intravenous (IV) bolus medication through a small-gauge IV catheter. The student notes that there is no blood return on aspiration. Which action by the student should the nursing instructor question? a. Checking the IV site for redness and swelling b. Immediately stopping the IV infusion and removing the IV catheter c. Checking to see if the IV is infusing without difficulty d. Injecting the IV medication if no signs of infiltration

ANS: B The student should stop the intravenous (IV), remove the catheter, and start a new one only if the line is not patent. In some cases, especially with a smaller-gauge IV catheter, blood return is not always aspirated, even if the IV is patent. Confirm patency. If the IV site does not show signs of infiltration and the IV fluid is infusing without difficulty, give the IV bolus medication. DIF: Cognitive Level: Applying REF: Text reference: p. 612 OBJ: Compare the risks of three different intravenous routes. TOP: IV Bolus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

4. The nurse is teaching a patient how to give a subcutaneous injection. The nurse includes which sites as acceptable for this route of administration? (Select all that apply.) a. Ventrogluteal area between the greater trochanter and the iliac crest b. Outer aspect of the upper arms c. Abdomen from below the costal margins to the iliac crests d. Anterior thighs

ANS: B, C, D The best subcutaneous injection sites include the outer aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs. These areas are easily accessible and are large enough that you can rotate multiple injections within each anatomical location. The ventrogluteal area is used for intramuscular injections. DIF: Cognitive Level: Applying REF: Text reference: p. 593 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Subcutaneous Injection Sites KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

4. The nurse is preparing a medication that comes in an ampule. Which action by the nurse is appropriate? a. Tapping the ampule so fluid moves from the bottom of the ampule to the neck b. Avoiding inversion of the ampule after opening to prevent spillage of the medication c. Using a filter needle long enough to reach the bottom of the ampule d. Guiding the needle against the rim of the ampule to access the medication

ANS: C Filter needles filter out any fragments of glass, and reaching the bottom of the ampule allows the medication to be completely withdrawn. The top of the ampule is tapped to move the fluid from the neck into the bottom of the ampule, where it is withdrawn. The ampule is held upside down or is set on a flat surface for withdrawal of the medication. The medication will not spill from the ampule after opening unless the needle tip or shaft touches the rim. The rim is considered contaminated and should not be touched by the needle. DIF: Cognitive Level: Applying REF: Text reference: p. 582 OBJ: Correctly prepare injectable medications from a vial and an ampule. TOP: Preparing Injections: Ampules and Vials KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

10. The nurse is teaching a family member of an obese patient how to administer a subcutaneous U-100 insulin injection to the patient. Which instruction should be included in the teaching plan? a. Carefully massage the site after the injection to aid absorption. b. Draw the medication into a tuberculin syringe with a 27-gauge needle. c. Insert the needle quickly and firmly at a 90-degree angle. d. Rotate injection sites between the abdomen, thighs, and upper arms.

ANS: C For an obese patient, the skin is pinched and the needle is inserted quickly and firmly at a 90-degree angle. Massage can damage underlying tissue. Subcutaneous U-100 insulin is given using an insulin syringe with a preattached needle of 28 to 31 gauge. Injection site rotation is no longer necessary because newer human insulins carry a lower risk for hypertrophy. Patients choose one anatomical area (e.g., the abdomen) and systematically rotate sites within that region—a practice that maintains consistent insulin absorption from day to day. DIF: Cognitive Level: Applying REF: Text reference: p. 598 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Insulin Injection KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

6. A patient has orders for 10 units of glargine insulin and 5 units of regular insulin to be given at the same time. Which action by the nurse is appropriate? a. Injecting 10 units of air into the glargine insulin vial first and not withdrawing the medication b. Injecting 5 units of air into the regular insulin vial first and then 10 units of air into the glargine insulin vial c. Giving two separate injections using different needles and syringes d. Withdrawing 5 units of regular insulin first and then calculating the total dose of regular and glargine insulin combined

ANS: C If long-acting insulin glargine is ordered, it should not be mixed with other insulin preparations, so two separate injections are prepared. Air is injected into one vial, and this is followed by withdrawal of the medication. It does not matter which one is drawn up first because they are in separate syringes. DIF: Cognitive Level: Applying REF: Text reference: p. 587 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Mixing Insulin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

22. The nurse is teaching a patient about continuous subcutaneous infusion with an insulin pump. What should the nurse include in the teaching plan? a. Rotate the site every 1 to 2 days. b. Place a gauze dressing over the insertion site. c. Select an insertion site in the abdomen away from the waistline. d. Pull the skin laterally before inserting the needle.

ANS: C Insulin is absorbed most consistently in the abdomen, so a site should be chosen in the abdomen away from the waistline. The site is changed every 2 to 7 days unless erythema or leaking occurs. An occlusive transparent dressing is used over the site. The skin should be gently pinched or lifted up to ensure that the needle will enter subcutaneous tissue. DIF: Cognitive Level: Applying REF: Text reference: p. 620 OBJ: Initiate, maintain, and discontinue a continuous subcutaneous infusion. TOP: Continuous Subcutaneous Infusion (CSQI) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

2. The nurse is preparing to administer an intramuscular (IM) injection to a 6-month-old infant. Which injection site is the most appropriate for this patient? a. Deltoid muscle b. Dorsogluteal injection site c. Vastus lateralis d. Abdomen 2 inches away from the umbilicus

ANS: C On the basis of the evidence, the vastus lateralis is the recommended site for pediatric IM injections for infants up to 12 months of age. The deltoid is the recommended site for children 18 months of age and older. The dorsogluteal site should not be used as an IM injection site. The abdomen is used for subcutaneous injection, not for IM injection. DIF: Cognitive Level: Applying REF: Text reference: p. 601 OBJ: Discuss factors to consider when selecting injection sites. TOP: Intramuscular Injection Sites in Children KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

8. The nurse is preparing to administer an intradermal injection to an adult patient. Which action should be taken by the nurse? a. Use a tuberculin syringe with a 1-inch 25-gauge needle. b. Inject no more than 1 mL of solution at one site. c. Insert the needle at a 5- to 15-degree angle 3 finger widths below the antecubital space. d. Expect a bleb and a small amount of bleeding after injection.

ANS: C The angle of insertion for an intradermal injection is 5 to 15 degrees. If possible, the site should be 3 to 4 finger widths below the antecubital space and one hand width above the wrist. To administer an injection intradermally, use a tuberculin or small syringe with a short (3/8 to 5/8 inch), fine-gauge (25 to 27) needle. Inject only small amounts of medication (0.01 to 0.1 mL) intradermally. If a bleb does not appear, or if the site bleeds after needle withdrawal, the medication may have entered subcutaneous tissue. In this situation, skin test results will not be valid. DIF: Cognitive Level: Applying REF: Text reference: p. 591 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Intradermal Injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

5. The nurse administers an injection of iron to a patient using the Z-track method. The nurse recognizes which of the following as advantages of this method? (Select all that apply.) a. Provides faster absorption of the medication. b. Reduces discomfort from the needle. c. Prevents leakage of the medication into subcutaneous tissue. d. Prevents the drug from irritating sensitive tissue.

ANS: C, D The Z-track method is recommended for IM injections. The Z-track technique, which pulls the skin laterally before injection, prevents leakage of medication into subcutaneous tissue, seals medication in the muscle, and minimizes irritation. DIF: Cognitive Level: Understanding REF: Text reference: p. 601 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Z-Track Method KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

9. The nurse administers a tuberculin screening test to a patient who has no known risk factors for tuberculosis (TB). When the test site is read 48 hours later, which result is considered positive? a. Induration of 2 mm or more b. Induration of 5 mm or more c. Induration of 10 mm or more d. Induration of 15 mm or more

ANS: D A raised, reddened, or hard zone around the test site indicates a positive tuberculin skin test. An induration of 15 mm or more indicates a positive reaction in patients with no known risk factors for tuberculosis (TB). An induration that measures 5 mm or more in diameter indicates a positive TB reaction in patients who are human immunodeficiency virus (HIV) positive, have fibrotic changes on chest radiograph consistent with previous TB infection, have had organ transplants, or are immunosuppressed. An induration of 10 mm or more indicates a positive TB reaction in patients who are recent immigrants; injection drug users; residents and employees in high-risk settings; patients with certain chronic illnesses; children younger than 4 years of age; and infants, children, and adolescents exposed to high-risk adults. DIF: Cognitive Level: Applying REF: Text reference: p. 592 OBJ: Evaluate the effectiveness and outcomes of administering medications by each injection route. TOP: Positive TB Test Results KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

19. The nurse is preparing to administer an intravenous (IV) antibiotic using a mini-infusion pump. Which action should the nurse do first? a. Place the syringe into the mini-infusion pump. b. Hang the pump on an IV pole. c. Connect the end of the mini-infusion tubing to the main IV line. d. Apply pressure to the syringe plunger to fill the tubing with medication.

ANS: D After connecting the prefilled syringe to the mini-tubing, the nurse carefully applies pressure to the syringe plunger to fill the tubing with fluid and to ensure that the tubing is free of air bubbles to prevent air embolus. After the tubing is filled with fluid, the syringe is placed into the mini-infusion pump and is hung on an IV pole. Then the mini-infusion tubing is connected to the main IV line. DIF: Cognitive Level: Applying REF: Text reference: p. 614 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Mini-infusion Pump KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

23. A patient has medication ordered to be given by intravenous (IV) bolus. The nurse recognizes which advantage of this type of administration? a. There is a slower onset of medication effects. b. Medications are given over a longer time frame. c. Medications given by IV bolus are less irritating to the veins. d. Small volumes are used, so fluid overload can be avoided.

ANS: D An intravenous (IV) bolus usually requires small volumes of fluid, which is an advantage for patients who are at risk for fluid overload. With IV bolus medications, rapid onset of medication effects occurs, which is useful for patients who are experiencing critical or emergent health problems. Medications can be prepared quickly and given over a shorter time frame rather than by IV piggyback. Medications given by IV bolus may cause direct irritation to the lining of the blood vessel. DIF: Cognitive Level: Analyzing REF: Text reference: p. 609 OBJ: Compare the risks of three different intravenous routes. TOP: Intravenous Bolus Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

16. After insertion of the needle into the patient's ventrogluteal muscle, the nurse aspirates and notices a very small amount of blood in the syringe. What action should the nurse take? a. Inject the medication slowly but smoothly. b. Withdraw the needle, expel the blood from the syringe, reinsert the needle, and inject the medication. c. Withdraw the needle, change the needle, insert the needle, and inject the medication. d. Withdraw the needle, dispose of the medication and syringe, and prepare another dose of medication.

ANS: D Aspiration of blood into the syringe indicates possible placement into a vein. If blood appears in the syringe, remove the needle, dispose of the medication and syringe properly, and prepare another dose of medication for injection. DIF: Cognitive Level: Applying REF: Text reference: p. 606 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Aspiration of Blood KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

11. The nurse is teaching a patient how to inject low-molecular-weight heparin. What instruction should be included in the teaching plan? a. The injection can be given in the abdomen or the upper thighs. b. Before injecting the medication, be sure to expel the air bubble in the syringe. c. After inserting the needle, pull back on the plunger of the syringe before injecting the medication. d. After injecting the medication, apply gentle pressure to the injection site for 30 to 60 seconds.

ANS: D Gentle pressure for 30 to 60 seconds prevents bleeding at the site. To minimize the pain and bruising associated with low-molecular-weight heparin (LMWH), it is given subcutaneously on the right or left side of the abdomen, at least 2 inches away from the umbilicus; this area is commonly referred to as a patient's "love handles." LMWH comes in a prefilled syringe, and the air bubble should not be expelled before administration. Aspiration after a subcutaneous injection is not necessary. Aspiration after an LMWH injection is not recommended. DIF: Cognitive Level: Applying REF: Text reference: p. 599 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Low-Molecular-Weight Heparin Injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity