nursing intervention 23
The nurse is preparing to give a patient a medication via a piggyback infusion. What is the safest action for the nurse to take? a. Fill the tubing with medication before connecting it to the Y-port. b. Obtain a second intravenous (IV) site where the infusion will be administered. c. Ask the patient his or her preference about starting a new IV line. d. Consult with the healthcare provider to obtain the best approach.
ANS: A Preventing air bubbles, which can cause an air embolus, is essential before attaching the the secondary infusion to the primary infusion line. There is no need to start a second IV site unless the medication is incompatible with what is running or if blood or blood products are infusing. The patient doesn't have the knowledge about what approach is best. The nurse should know what to do in this situation.
The nurse prepares an insulin injection for the patient who has diabetes mellitus. Which does the nurse implement for correct insulin administration? a. Gives regular insulin within 15 to 30 minutes of meals b. Injects insulin just removed from the refrigerator c. Examines vials of NPH insulin for abnormal cloudiness d. Administers NPH insulin for sliding-scale insulin dosing
ANS: A The nurse administers regular insulin subcutaneously within 15 to 30 minutes of the patient's meal because it starts to work in 30 minutes to 1 hour; thus the patient eats around the same time as the insulin administration to avoid severe hyperglycemia, which occurs if the patient eats and does not take insulin, or hypoglycemia, which occurs if the patient does not eat and takes insulin. Although insulin generally is stored in a refrigerator to prevent decomposition, it needs to be at room temperature when administered. The nurse can draw up the dose and have it checked; then it will be time to administer it. NPH insulin has a cloudy appearance. Regular insulin is used for sliding-scale insulin and as needed insulin.
The nurse is teaching a patient to self-administer insulin. The patient is 5 feet tall and weighs 197 pounds. Which of the following does the nurse include in patient teaching? a. Insert the needle into abdominal tissue at a 90-degree angle. b. Include an air space when drawing up the prescribed dose. c. Aspirate before injecting to ensure that the needle is not in a vessel. d. Instruct the patient to use an insulin syringe with a 1-inch needle.
ANS: A The nurse instructs the patient to insert the needle at a 90-degree angle to inject insulin into subcutaneous tissue because the patient is obese and likely to have excessive abdominal adipose tissue. The 5/8-inch needle is long enough to reach subcutaneous tissue for proper administration of insulin but not long enough to reach muscle. The nurse instructs the patient to remove all air bubbles from the syringe before administering the insulin. Aspiration is unnecessary for subcutaneous injections because the tissue is avascular. A 1-inch needle is unnecessary because a 5/8-inch needle reaches the same subcutaneous tissue in this patient as a 1-inch needle.
The nurse prepares to administer 2.2 mL of an oil-based medication intramuscularly to a male patient who is 5 feet 10 inches tall and weighs 165 pounds. Which needle and syringe combination should the nurse choose to administer the injection? a. 20-gauge, 1 1/2-inch needle on a 3-mL syringe b. 21-gauge, 1 1/2-inch needle on a 5-mL syringe c. 23-gauge, 1-inch needle on a 3-mL syringe d. 25-gauge, 1-inch needle on a 5-mL syringe
ANS: A The patient is well proportioned; because the medication is a thick solution requiring a deep intramuscular (IM) injection, the nurse chooses a slightly larger gauge needle, 20-gauge, which is 1 1/2 inches long, to accommodate the thick medication and to reach deep within the muscle. A 21-gauge needle is appropriate, but the syringe is too large. A 23-gauge needle is too small, and the oil would not be able to get through the lumen. A 25-gauge, 1-inch needle is far too narrow and short for an IM injection.
The nurse instructs a patient's partner to administer subcutaneous regular Humulin insulin. What information should the nurse include in the partner's teaching? a. Select a 25-gauge, 5/8-inch needle. b. Massage the site after the injection. c. Always insert the needle at a 90-degree angle. d. Use a different injection site each time.
ANS: A To ensure subcutaneous delivery of the insulin, the nurse instructs the partner to use a 25-gauge, 5/8-inch needle and to insert the needle at a 45- to 90-degree angle into the elevated skin area. The nurse instructs the partner to avoid massaging the injection site. The needle is inserted at a 45- to 90-degree angle, depending on the site and the amount of subcutaneous tissue present. Rotating sites is unnecessary with Humulin insulin because antibodies are much less likely to form and cause hypertrophy of tissue.
The nurse prepares to administer a 3-mL intramuscular (IM) injection of an antibiotic to an 85-year-old patient. What action does the nurse take to administer the medication correctly? a. Prepares the patient for a subcutaneous injection b. Divides the injection into two separate syringes c. Positions the patient for injection in the dorsogluteal area d. Avoids aspirating when injecting in the deltoid muscle
ANS: B Older adults may have decreased muscle mass and can tolerate up to 2 mL of an injection; thus the nurse divides the dosage into two separate IM injections to promote patient comfort and prevent tissue damage. A 3-mL injection contraindicates use of the subcutaneous route; subcutaneous injections range from 0.5 to1 mL in volume. The nurse avoids the dorsogluteal area because of the risk of injury to the sciatic nerve and aspirates during IM injections, regardless of the location.
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 solution? 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.
ANS: 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.
The nurse evaluates the patient's ability to self-administer a subcutaneous injection of the anticoagulant enoxaparin (Lovenox). What action by the patient indicates a need for additional patient teaching? a. Insert the needle at a 45- to 90-degree angle. b. Massage the area after performing the injection. c. Administer the injection without aspirating. d. Inject at least 7.6 cm (3 inches) from the umbilicus.
ANS: B The nurse wants the patient to avoid massaging the injection site after administering enoxaparin to prevent the formation of large hematomas and decrease the risk of additional bleeding and tissue damage. The nurse instructs the patient to inject the enoxaparin and withdraw the needle without massaging the site afterward. If the patient massages the area to dispel pain or discomfort, he or she reports this to the nurse or provider because it is an unusual finding. The patient demonstrates proper injection technique with injections at 45 to 90 degrees, avoiding aspiration and injecting at least 2 inches away from the umbilicus.
A patient is admitted to the emergency department after a motor vehicle accident. The nurse sustains an accidental needlestick injury while performing a venipuncture on the patient. What is the nurse's priority? a. Determine whether the needle was sterile. b. Follow agency policy for employee injuries. c. Inform the provider to screen the patient for antibodies. d. Obtain patient history of communicable diseases.
ANS: B The nurse's priority after a needlestick injury is obtaining immediate treatment as outlined in agency policy. He or she needs baseline testing and, depending on the patient's history and test results, administration of preventive treatments. The needle cannot be sterile after a venipuncture. The nurse's priority is his or her own safety and receiving prompt treatment; informing the provider and gathering subjective data are secondary in importance.
The nurse evaluates the tuberculosis skin test results for a patient who recently emigrated from Southeast Asia. Which result is consistent with the presence of tuberculosis antibodies in the patient's system if the nurse reads the test 72 hours after injection? a. The injection site is an 11-mm red, warm, swollen area. b. The skin around the injection site is black, dry, and scaly. c. The nurse palpates a hard, dense, raised area 14 mm across. d. According to the patient, the skin around the injection site feels cool.
ANS: C A tuberculin skin test indicating the presence of antibodies results in a palpable, indurated area at the injection site greater than 10 mm in diameter for a recent immigrant from Southeast Asia because many immigrants from that area are exposed to tuberculosis. In addition, tuberculosis immunizations are common in Southeast Asia; if a patient is tested after receiving the tuberculosis vaccine, the intradermal skin test will always be positive. Patients with no known risk factors have a positive test with a 15-mm induration, and an immunocompromised patient has a positive test with a 5-mm induration. This site is suspicious, but if it is not indurated, it does not indicate a positive result. Black, dry, scaly skin is consistent with necrotic tissue. A cool sensation around the injection site after a tuberculin skin test is an unusual finding.
The patient wants to receive insulin by continuous subcutaneous injection (CSCI). Which injection site does the nurse suggest for the patient? a. The upper arm b. The upper chest c. The lower abdomen d. The thigh
ANS: C The nurse instructs the patient to use the tissue in the lower abdomen, which has sufficient subcutaneous tissue and where insulin is most consistently absorbed. The upper arm and thigh are potential sites, but since most patients are active, the needle could become displaced with normal activity. The upper chest does not have as much subcutaneous tissue as the abdomen.
Which technique does the nurse use to administer a parenteral medication properly? a. Inserts the needle with the bevel facing downward b. Pushes the needle through the patient's tissue slowly c. Applies sterile technique to draw up the medication d. Uses a 16- or 18-gauge needle with aqueous solutions
ANS: C The nurse uses sterile technique while drawing up the medication and for needle changes to prevent the introduction of pathogens to the patient and increased risk of infection. The hub and the inside of the syringe are sterile, as is the needle. The nurse attaches a sterile needle with the cap firmly in place to the syringe without contaminating the hub of the syringe. The nurse removes the cap without contaminating the needle to inject the medication. The bevel remains up for an injection. The nurse quickly inserts the needle into the patient to minimize the pain. Sixteen-gauge needles are not used for injections into soft tissue; oil-based, viscous solutions require an 18- to 25-gauge needle.
The nurse is reviewing the records of four patients on heparin therapy. Which patient does the nurse determine has the highest risk for a bleeding disorder during heparin therapy? a. A 10-year-old patient with an acute viral infection b. A female patient who gave birth more than 6 weeks ago c. A patient who takes a nonsteroidal antiinflammatory drug d. A 60-year-old patient with kidney stones
ANS: C The patient who takes a nonsteroidal antiinflammatory drug has the highest risk of a bleeding disorder complicating heparin therapy because this classification of medication has known risk factors for bleeding, especially gastrointestinal bleeding. The patient who gave birth more than 6 weeks ago probably has the second highest risk. After 6 weeks' postpartum, involution is usually complete; thus hemorrhaging from the uterus is unlikely. The patients with the acute viral infection and kidney stones have a lower risk of bleeding while on heparin.
The nurse is preparing to administer the anticoagulant enoxaparin (Lovenox) subcutaneously. Which injection site is most appropriate for the nurse to use? a. Thighs b. Deltoid area c. Sides of abdomen d. Ventrogluteal area
ANS: C The sides of the abdomen are the preferred injection sites for enoxaparin to minimize bruising and discomfort. There are no major blood vessels or nerves in these areas. The nurse avoids injecting enoxaparin into the thighs because it potentially increases hematoma formation and discomfort from physical activity. The nurse avoids injecting enoxaparin into the deltoid region because it is likely to be more visible; in addition, patient activity can increase the risk of hematomas and discomfort. The nurse avoids the ventrogluteal site because injecting there potentially increases discomfort when the patient is trying to rest.
The nurse is preparing to give an injection in the ventrogluteal injection site. Which pair of anatomical landmarks does the nurse use for this site? a. Greater trochanter and knee b. Acromion process and axilla c. Anterior superior iliac spine and iliac crest d. Posterior superior iliac spine and iliac crest
ANS: C To locate the ventrogluteal muscle with the patient on the left side, the nurse palpates the head of the femur and the anterior superior iliac spine with the left hand. Place the heel of the right hand on the greater trochanter, with the thumb pointing to the groin and the index finger toward the anterior superior iliac spine. Extend the middle finger back to the iliac crest toward the buttocks, creating a V between the index finger and the middle finger; the injection site is deep in the middle of this V. The remaining anatomical landmarks are used with other sites, not the ventrogluteal.
The nurse prepares an IM injection to administer a medication available in a glass ampule. Which step does the nurse take to administer the injection properly? a. Labels the ampule with date and time of the first dose b. Ensures that the cartridge is fully seated into the syringe c. Cleans the rubber top carefully before inserting the needle d. Uses a filter needle to withdraw the contents of the ampule
ANS: D An ampule is a glass container for a single dose of medication. The nurse protects the hands to break open the ampule and removes its contents with a syringe and filter needle to prevent aspiration of glass fragments. The nurse removes the filter needle and replaces it with a regular needle before administering the medication to the patient. Ampules are not amenable to reuse because they are open to air and thus contamination. The nurse opens an ampule and withdraws the contents into a syringe; a cartridge of medication is a prefilled syringe used with a reusable injection device. Ampules do not have rubber tops.
The nurse is caring for a 14-year-old patient with diabetes mellitus who does not want to self-administer insulin because it is too painful. Which information should the nurse use in response to the patient's concern? a. Adolescents are usually enthusiastic about self-care. b. Insulin mixed with a local anesthetic decreases pain. c. The healthcare provider orders oral insulin for patients with pain. d. There are techniques that will minimize the pain of the injection, though not eliminate it.
ANS: D Insulin injections are likely to cause mild pain but there are techniques that may be taught to the patient to minimize the pain. The pain will not be eliminated, and this information needs to be shared with the patient. Initially many adolescents are unenthusiastic participants in insulin self-administration. The nurse avoids mixing insulin with a local anesthetic because the benefit does not outweigh the risk. Oral insulin is not available.
The nurse instructs a patient with diabetes mellitus about subcutaneous insulin administration. What does the nurse include in patient teaching? a. Remember that NPH insulin peaks within 15 minutes. b. Prepare for hyperglycemia 2 hours after taking insulin. c. Keep insulin refrigerated after administering the first dose. d. Eat right after taking regular insulin to avoid hypoglycemia.
ANS: D Regular insulin peaks 15 to 30 minutes after subcutaneous administration; thus the patient needs to eat right after administering the insulin to prevent a hypoglycemic emergency. Once it is administered, the insulin begins to drive glucose into the cells, resulting in a lower blood sugar; thus, if the patient does not eat to sustain the blood sugar, he or she becomes hypoglycemic. NPH, intermediate-acting insulin, peaks 2 to 6 hours after subcutaneous administration. Because insulin drives glucose into the cells, the blood sugar is more likely to drop than to increase after insulin administration. The nurse teaches the patient to store insulin at room temperature as long as the patient is the only person using the insulin vial.
When administering an intramuscular (IM) injection, the nurse obtains blood during aspiration. What action by the nurse is appropriate? a. Wait 30 minutes before giving the ordered medication. b. Notify the healthcare provider of the situation. c. Continue to administer the ordered medication. d. Stop the administration and discard the syringe.
ANS: D The injection is stopped, the needle is withdrawn, and the filled syringe is discarded. A new dose of medication is prepared in a new syringe with a new needle for the patient. Waiting 30 minutes is not necessary because the medication is due and can be given as soon as a new syringe is prepared. Notifying the healthcare provider is unnecessary. Continuing with the injection is dangerous because the medication could be given intravenously instead of intramuscularly.
Which angle should the nurse use to administer an intramuscular (IM) injection for a patient who is 5 feet 6 inches tall and weighs 140 pounds? a. 15 degrees b. 45 degrees c. 60 degrees d. 90 degrees
ANS: D The nurse administers an IM injection at a 90-degree angle to the surface to ensure injecting the medication into the muscle. An angle less than 90 degrees increases the risk of injecting the medication into subcutaneous tissue.
The nurse administers intradermal injections for allergy testing. Which is the best technique for the nurse to use for skin testing? a. Select a 22-gauge needle. b. Inject at a 45-degree angle. c. Choose the back for the first test. d. Inject below the antecubital space.
ANS: D The nurse chooses a clear site without bruises, inflammation, edema, or other factors that potentially impair absorption. Three to four fingerbreadths below the antecubital space or 1 handwidth above the wrist are suitable sites. The nurse can use both arms if more extensive testing is indicated because each forearm can manage 12 to 20 tests. A 22-gauge needle is too large. The nurse injects at a 5- to 15-degree angle. The back is a suitable testing site, but the forearms are better because they are accessed more easily and visible.
The nurse is teaching a patient to self-administer subcutaneous heparin at home. What does the nurse include in patient teaching? a. Use a 22-gauge, 1-inch needle for the heparin injections. b. Change needles after withdrawing the heparin from the vial. c. Instruct the patient and family to recap all needles used at home. d. Pinch a large area of skin and inject heparin into the center of the skin fold.
ANS: D The nurse instructs the patient to grab a large pinch of skin and inject the heparin into the center of the skin fold at a 90-degree angle to deposit the medication into subcutaneous tissue. A 22-gauge needle is too large for a subcutaneous injection; a 25- or 27-gauge needle is a better choice because a finer needle creates a smaller hole. As a result, the medication tends to remain in the subcutaneous space, the patient is more comfortable, and the skin develops scar tissue more slowly. Changing needles is not necessary. Needles are never recapped; the patient at home should obtain a sharps container or use an impenetrable container to hold used needles. The patient should label the container to prevent injury to others.
The nurse's outcome for the patient is, "Patient self-administers subcutaneous heparin before discharge." What does the nurse include in patient teaching? a. Expect large areas of bruising around the injection site. b. Promote heparin absorption by massaging the injection site. c. Choose one large area for consistent heparin absorption. d. Inject heparin into the abdomen but avoid the umbilical area.
ANS: D The nurse instructs the patient to inject heparin into the abdomen and avoid the area around the umbilicus because it is surrounded by dense tissue that delays absorption. The nurse instructs the patient to expect small areas of bruising around the injection site; to avoid massaging the site because it increases absorption and promotes bruising; and to choose various sites, reminding the patient that bruising occurs and the patient may want to keep the areas covered.
The nurse prepares to administer an irritating medication by the Z-track technique. Which technique does the nurse use to administer this intramuscular (IM) injection properly? a. Inserts the needle and pulls the skin laterally before injecting the medication b. Has the patient lie in a supine position to prevent medication leakage c. Waits 10 seconds and releases the skin before withdrawing the syringe d. Pulls the patient's skin laterally before inserting the needle
ANS: D The nurse pulls the patient's skin to the side before inserting the needle using the Z-track technique to prepare the seal for the medication after injection. When the skin is released after the needle is withdrawn, it assumes its original place and helps to contain the medication. The nurse retracts the patient's skin and inserts the needle. Supine positioning does not prevent medication leakage. The nurse waits 10 seconds but withdraws the needle and then releases the skin.
The nurse needs to administer an intramuscular (IM) injection to a patient who is 7 months old. Which is the best site for the nurse to use for the injection? a. Deltoid b. Dorsogluteal c. Ventrogluteal d. Vastus lateralis
ANS: D The preferred IM injection site for patients under the age of 12 months is the vastus lateralis muscle because it is a relatively large muscle mass without major nerves and blood vessels, has a consistent layer of fat, and has a good safety record. The deltoid is suitable for well-developed children and adolescents with use of a 5/8-inch needle. The dorsogluteal site is contraindicated because of the major anatomical structures that it contains. The ventrogluteal site is a safe site for injections in all age-groups; however, the vastus lateralis is the preferred site for infants.
The nurse is providing teaching for a patient who needs an intradermal test for tuberculosis. What information should the nurse include? a. Check with the healthcare provider in 2 hours for test results. b. Relaxation helps make this type of injection painless. c. A total of 0.1 mL of solution will be injected into the muscle. d. The test must be read in 48 to 72 hours.
ANS: D The time period for reading the results of the tuberculin skin test is within 48 to 72 hours after it has been done. The nurse or provider reads the test results 48 to 72 hours after the injection. Relaxation doesn't make a difference since the procedure involves a minor skin prick and generally causes a mild transient pain. The nurse injects 0.1 L of solution but not into the muscle.
A toddler is to receive an intramuscular injection. What action can the nurse take to make the injection less traumatic? a. Have the parents hold the toddler down during the injection. b. Collaborate with the healthcare provider about what to do. c. Encourage the toddler to move the leg after the injection. d. Obtain an order for EMLA cream or vapo-coolant spray.
ANS: D Use of EMLA cream on the injection site l hour before the injection or vapo-coolant spray just before the injection decreases the pain. The parents should support the child during the injection, not help to hold him or her down during a painful procedure. The nurse should know what to do and does not need to ask the healthcare provider. Moving the leg after the injection helps to disperse the medication but does nothing about the trauma of the injection.