EAQ 35

The medical-surgical nurse knows that which goal would be most appropriate for the postoperative patient related to the nursing diagnosis of activity intolerance?

Pain will be relieved by medication for 3 hours.

Which intervention would the nurse implement to ensure patient safety when administering an intramuscular (IM) injection to a slender older adult patient?

Palpating and grasping the muscle before the injection

Which statement by the student nurse indicates that teaching regarding vials has been effective?

"The top of the vial has a rubber stopper attached with a metal band."

Which follow-up question would the nurse ask a patient who is self-administering subcutaneous heparin injections with heparin on noting several areas of ecchymosis on the patient's abdomen?

"Can you describe to me how you are giving yourself the shot?" Heparin given subcutaneously can cause bleeding into the tissues. Massaging the site after a heparin injection may cause bruising of the tissues and increases the likelihood of ecchymosis (purplish area under the skin caused by bleeding) formation. It is important to rotate injection sites to prevent tissue irritation and to improve absorption of the medication, but this is not the most likely cause of the ecchymosis formation. Needle size is determined by the type of injection (intradermal, subcutaneous, intramuscular, or by patient size); needle size would not cause areas of ecchymosis. Diet would not affect heparin; vitamin K is an antidote for coumadin, another anticoagulant.

Which question would be most important for the occupational health nurse to ask a patient who experiences an induration of 5 mm in diameter after administration of a tuberculin skin test on a routine screening for employment?

"Have you ever been told that your immune system is compromised?"

Which response by the nurse would be correct when a patient asks why the nurse did not massage the injection site after administering subcutaneous heparin?

"It may cause bleeding or bruising of the tissue."

Which information would the nursing instructor include in teaching students regarding the Z-track technique for administering intramuscular injections? Select all that apply. One, some, or all responses may be correct.

-The Z-track technique avoids the leakage of drugs into the subcutaneous tissue. -This technique is used to prevent skin staining from preparations such as iron.

Which is the most appropriate response by the nurse when asked "Why is the ventrogluteal site preferred instead of the dorsogluteal site for intramuscular injections?"

"There is a risk for injury to the blood vessels and the sciatic nerve." The term gluteal pertains to the buttocks. In the past, the dorsogluteal site was used for IM injections, but evidence-based practice indicates that there is a risk for injury to the blood vessels and the sciatic nerve. It is not difficult to locate the dorsogluteal site in any patient. The mid-deltoid muscle should not be used in infants. The ventrogluteal site is used in older adult patients. Stick injuries are caused at any site if proper precautions are not taken.

The nurse in a pediatric office needs to administer a routine influenza vaccine to a 6-year-old who is struggling and won't sit still on the exam table. Which statement can the nurse make to the child to facilitate giving the vaccine?

"This injection will help keep you from getting sick and will only hurt for a minute."

Which action would the nurse at an immunization clinic perform when a patient who recently received an injection develops hives, wheezing, and appears apprehensive? Select all that apply. One, some, or all responses may be correct.

-Applying oxygen -Notifying the primary health care provider -Bringing the crash cart into the room -Preparing to begin cardiopulmonary resuscitation -Preparing to administer emergency drugs

Which precaution would the nurse take when preparing an injection to prevent infections? Select all that apply. One, some, or all responses may be correct.

-Avoiding contact of the needle with the ampule -Cleansing the patient's skin with an antiseptic swab - covering the tip of the syringe with a cap

In which order would the nurse withdraw and mix different types of insulin into the same syringe?

-Inject air in the long-acting (cloudy) insulin. -inject air in the short-acting (clear) insulin. -Withdraw the desired dose from the short-acting (clear) insulin - Withdraw the desired dose from the long-acting (cloudy) insulin

Which precaution would the nurse take when administering a subcutaneous injection? Select all that apply. One, some, or all responses may be correct.

-Injecting the medication slowly -Injecting the needle at a 45- or 90-degree angle -Pinching the patient's skin with the nondominant hand

Which information would help the patient ensure correct self-administration of insulin

-Insulin is given as a subcutaneous injection. -Insulin is absorbed quickly when injected into the abdomen. -The upper arm, thigh, abdomen, and buttocks are preferred sites.

Which consequence would occur if the nurse selects an improper site for injection? Select all that apply. One, some, or all responses may be correct.

-Necrosis -Abscesses -Nerve damage -Sloughing of skin

After teaching a patient to self-administer insulin using an insulin pen, which patient action would indicate to home care nurse that teaching was successful? Select all that apply. One, some or all responses may be correct.

-Turning the dose knob until the arrow appears in the window. -Counting to five after injection before removing the needle from the skin. -Pulling out the dose knob and turning it to dial in the correct number of units. Correct use of an insulin pen includes turning the dose knob until the arrow appears in the window. The pen is now ready for the dose to be dialed in; this action is accomplished by pulling out the dose knob and turning it to dial in the correct number of units. After injection, the patient should wait 5 seconds before removing the needle from the skin. After use, the insulin pen should be stored at room temperature, but away from heat or light; it should not be refrigerated. After an injection, the needle would be unscrewed and discarded.

Which length needle would the nurse use to administer an intramuscular injection?

1½ inch

Which size needle would the nurse use to administer an intramuscular (IM) injection into a large muscle?

21-gauge

Which size needle would the nurse retrieve from the supply room to administer a subcutaneous injection?

25-gauge

Which action would the nurse take when noting that a patient with Type I diabetes mellitus (DM) has fatty lumps under the skin of the abdomen?

Instructing the patient to rotate injection sites to other body areas

At which angle would the nurse insert the needle into the skin when administering a subcutaneous injection with a small-gauge needle to a patient

90 degree angle

The nurse is caring for a patient who experiences a hypoglycemic event secondary to an incorrect dose in regular insulin being given before breakfast. The patient is stabilized, the error is documented, and a root cause analysis is later undertaken. Which injection device, if used, would be the cause of the error in dosing?

A 1-cc tuberculin syringe Insulin and tuberculin syringes are both small-gauge syringes and are easily confused. To deliver an accurate insulin dose, the nurse would use an insulin syringe with a scale that is marked in units. A tuberculin syringe's scale is marked in milliliters. Administering insulin with a tuberculin syringe precludes that the correct dose of insulin is given. Some medications, but not insulin, are available in prefilled unit-dose cartridges. Insulin syringes come in different sizes and for insulins of different concentrations. The U-50 insulin syringe is calibrated to measure 50 units of insulin, and the U-100 insulin syringe is calibrated to measure 100 units of insulin.

Which equipment would the nurse use to administer an intradermal injection with 0.1 ml of medication to a patient for an allergy test

A tuberculin syringe with 25-gauge needle

Which route of medication administration would be correct when performing a tuberculin skin test?

Intradermal

Which instruction would the nurse provide the patient regarding preparation of regular insulin and neutral protamine Hagedorn (NPH) insulin?

Administer both doses 15 minutes before a meal. Roll the cloudy insulin vial between the palms of the hands. Draw up the regular insulin first, and then draw up the NPH insulin.

Which technique would the nurse use to administer heparin?

Administering the injection subcutaneously

Which intervention would nurse implement when giving an intramuscular (IM) injection of iron dextran to a child?

Administering the medication using the Z-track technique

For which reason would the nurse wait for 10 seconds before withdrawing the needle when injecting iron dextran using the Z-track method?

Allows the medication to disperse in the tissue

Which type of medication would the postanesthesia care unit (PACU) nurse give to relieve postoperative discomfort?

Analgesic

Which measure would the nurse take to decrease injection discomfort when administering an intramuscular injection to a child?

Apply EMLA cream 1 hour before the injection to numb the skin.

Which factor would the nurse use to determine which needle to use in administering an injection to a patient?

Body mass of the patient Viscosity of the medication Type of injection prescribed

Which technique would the nurse inform the patient about regarding allergy testing?

Intradermal (ID) injection

Which step would the nurse take immediately after drawing up iron dextran using a syringe and needle?

Changing the needle to a new safety needle

Which assessment will the nurse make before administering heparin to a patient with deep vein thrombosis:

Checking activated partial thromboplastin time (aPTT) Heparin is an anticoagulant that prevents the formation of blood clots; it disrupts the clotting cascade and increases the time the blood takes to clot. The nurse would monitor the aPTT level before administering heparin; the aPTT is a laboratory test that measures in seconds how long it takes blood to clot. Heparin does not affect urinary output, blood pressure, or peripheral pulses.

The nurse would be vigilant for which symptom of pulmonary emboli in a patient who has a deep venous thrombosis?

Chest pain Shortness of breath Change in mental status Pulmonary emboli are blood clots in the arteries of the lungs. They reduce blood flow to the lungs, resulting in chest pain and shortness of breath. In later stages, pulmonary emboli can also affect mental status. Urticaria is a symptom of an anaphylactic reaction. Drowsiness is observed after administering preoperative sedatives.

Which severe complication associated with allergic reaction would the nurse need to prevent:

Circulatory collapse

Which action would be important for the nurse to perform when administering medication from an ampule? Select all that apply. One, some, or all responses may be correct.

Replacing the needle used to draw up medication with another sterile needle before injection Using a filter needle to draw up the medication

Which site would the nurse choose for administering an intramuscular injection to a patient? Select all that apply. One, some, or all responses may be correct.

Deltoid Ventrogluteal Vastus lateralis

Which action would be important for nurses to perform to protect themselves from becoming a victim of a needle stick injury?

Developing a conscious awareness of where contaminated needles may be left

In which way would the nurse make a child comfortable before administering a prescribed immunization injection?

Explain the purpose of the injection, and demonstrate the procedure on a doll.

For which complication of subcutaneous injections would the nurse monitor? Select all that apply. One, some, or all responses may be correct.

Pain Hypertrophy of the skin Sterile abscess

Which is the most likely reason for the nurse to visually check an ampule neck and tap the ampule stem:

Freeing the trapped solution from the neck of the ampule

The nurse needs to administer an injection of penicillinG intramuscularly to a patient with a severe streptococcal infection. The drug, when reconstituted, amounts to 4 milliliters (mL) total. In which way will the nurse administer the medication?

Giving two injections of 2 mL each into the left and right vastus lateralis sites

Why would the nurse ask another nurse to double-check the syringe for the right drug and dosage before administering heparin to a patient?

Heparin is a "high-alert" drug and requires additional verification

In which position would the nurse tell the patient to lie before injecting an intramuscular (IM) injection to the vastus lateralis site?

In the prone position with the toes turned inward The vastus lateralis is the area between the anterolateral and the midlateral thigh. While administering an IM injection in this site, the nurse would ask the patient to lie in the prone position with the toes turned inward. In this way, the muscle is relaxed and the injections cause less pain. The gluteal muscles are tensed when the hip is extended or the leg is externally rotated; this can be avoided by turning the toes inward. Lying on the side, extending the hands, lying comfortably with the legs apart, or lying in the prone position with the hands loosely at the sides would be incorrect positions for injecting.

Which site would the nurse select for administering an intradermal injection to the patient?

Inner aspect of the forearm

Which injection site, if selected to administer a subcutaneous injection by the student nurse, would prompt the nursing instructor to intervene immediately?

Inner surface of forearm

Place the steps in correct order when withdrawing medication from an ampule.

Insert a sterile filter needle into the solution. Keep the bevel below the surface of the medication to draw the appropriate dose. Draw air, and make a large bubble in the syringe. Tap the syringe to move the air bubble toward the needle. Push the plunger to expel air until a drop of liquid appears in the bevel.

Which action would the nurse perform to ensure safety when withdrawing medication from a vial

Inserting a needleless device into the rubber stopper at a slight angle Use of a needleless device for withdrawing medication from a vial is recommended because inserting the device at a slight angle prevents "coring" of the stopper. Coring occurs when a small piece of the stopper is pushed into the bottle; it becomes a source of contamination. The amount of air injected into a vial to prevent a vacuum from developing should always equal the amount of medication that is withdrawn. Injecting too much air may create pressure that wastes the medication by pushing it out of the vial when the stopper is punctured. An open multidose vial that still contains medication is labeled with the time and date it was opened and placed in the refrigerator. Pushing a needle straight down into the stopper of a vial may cause coring to occur.

Which step would the nurse take immediately after medication is drawn into the syringe for parenteral administration?

Labeling the syringe with patient and medication information

Which action would the nurse perform to ensure that a tuberculin skin test was correctly administered to a patient?

Looking for the formation of a bleb at the insertion site

Which nursing intervention may result in a complication when administering subcutaneous heparin?

Massaging the site after injecting heparin Massaging after injecting heparin via the subcutaneous route can result in tissue bruising, bleeding, and severe ecchymosis and can alter the rate of absorption. Aspirating before administering heparin can result in tissue bruising. Wiping the injection site with alcohol prevents infection.

The nurse is teaching a family member how to administer insulin injections to a patient in preparation for discharge. Which action by the family member, would indicate the need for further teaching?

Recapping the needle after the injection

Which action would the nurse perform to help prevent tissue fibrosis when administering insulin to a patient?

Rotating sites for insulin administration

Which detail would the nurse include in the documentation of administration of a routine injection? Select all that apply. One, some, or all responses may be correct.

Route Dosage Medication Injection site

Which fluid is commonly used to dissolve drugs that are made in a solid form and are unstable in solution? Select all that apply. One, some, or all responses may be correct.

Sterile water Sterile normal saline

Which route would be appropriate for administering medications parenterally? Select all that apply. One, some, or all responses may be correct.

Subcutaneous (SC) route Intradermal (ID) route Intravenous (V) route Intramuscular (IM) route

Which indication in laboratory test results would confirm the effectiveness of subcutaneous heparin?

The activated partial thromboplastin time (APTI) laboratory value becomes therapeutic. When heparin is subcutaneously administered for treating blood clots, its effectiveness would be reflected by the APTT laboratory value being within therapeutic limits. Its effectiveness can be judged clinically by the absence of calf pain or swelling, which are signs of new clots. The RBC count becomes normal after administering an iron dextran injection. A patient would become drowsy and relaxed after administering preoperative sAdatives.

Which indication in laboratory test results would confirm the effectiveness of subcutaneous heparin?

The activated partial thromboplastin time (APTT) laboratory value becomes therapeutic.

Which action by a patient self-administering heparin subcutaneously would indicate to the home care nurse that patient teaching was successful?

The drug is injected into the abdomen

Which is the most likely reason for the nurse to gently pick up the tissue between the thumb and index finger before giving a subcutaneous injection?

The nurse can assess the thickness of the subcutaneous layer. Before administering a subcutaneous injection, the nurse would gently pick up the skin at the site to assess the thickness of the subcutaneous layer; this prevents the medication from being injected into the muscle instead of the subcutaneous layer. he site of injection is already identified and selected by the nurse. Pinching the skin would not help identify the site. Picking up the skin does not alleviate the pain in the patient. Needle stick injuries occur if the needle is not handled efficiently.

Which concept would the nurse utilize regarding drug reconstitution?

The solute must be mixed with the diluent before use.

Which is the rationale for the nurse to drop the needle in the sharps container after administering an injection?

The used needle is dropped to reduce needle stick injuries.

Which part of the syringe must be kept sterile? Select all that apply. One, some, or all responses may be correct.

Tip Needle Side of plunger

For which reason would the nurse replace the regular needle with a sterile filter needle before drawing up medication from an ampule?

Traps any glass particles that may fall in the drug

Which nursing measure would be helpful in minimizing medication errors?

Understanding drug action Using two patient identifiers Identifying the appropriate route

Which symptom requires emergency intervention when administering a new medication to a patient with a history of allergies? Select all that apply. One, some, or all responses may be correct.

Urticaria Bronchiolar constriction Severe hypotension

Which action by the student nurse indicates effective learning when withdrawing medication from an ampule?

Using a sterile filter needle to withdraw the medication

Which precaution would the nurse take before administering an intramuscular injection to a patient? Select all that apply. One, some, or all responses may be correct.

Using disposable, sterile equipment Ensuring that the medications are readily absorbable Reviewing patient allergies

Which action by the patient would indicate a need for further teaching regarding the use of an insulin pen?

Using the same needle every time the pen is used for an injection

Which site is used for intramuscular (IM) injections for infants younger than 12 months of age?

Vastus lateralis

Which site would the nurse select to administer an intramuscular injection to an 11-month-old patient?

Vastus lateralis

Which laboratory parameter would the nurse check to evaluate the effectiveness of an antibiotic?

White blood cell count

Which action by a patient drawing up a long-acting and short-acting insulin for self-injection would indicate the need for further teaching?

Withdrawing the long-acting insulin first and then withdrawing the short-acting insulin

Which route of administration would the nurse choose for a patient requiring fast action of an antibiotic?

parenteral

Which route of administration would the nurse choose for a patient requiring fast action of an antibiotic?

parenteral Rationale A parenteral route of injection is used to hasten the action of a drug. Drug action is slower when given in the oral form. Antibiotics are not given via the rectal or inhaled route of administration.