Skills Chapter 22

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

B

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

B

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.

B

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

A

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

A

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

A

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

A

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.

A

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.

A

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 regularinsulin from the vial

A

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

A, B, C

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

A, B, C

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

A, B, C, D

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

A, B, D

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.

B

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

B

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.

D

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

B, C, D

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.

C

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

C

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.

C

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.

D

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

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.

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.

C, D

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

D

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

D

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.

D

The nurse is preparing a medication that comes in an ampule. Which action by the nurse is appropriate?

Using a filter needle long enough to reach the bottom of the ampule

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?

Vastus lateralis