Skills Test #5

The nurse is administering an intramuscular injection of cortisone to a client. What action would the nurse take immediately following the injection?

Apply gentle pressure with a dry gauze. Rationale: After administering an intramuscular injection, the nurse would apply gentle, not firm, pressure at the site with a dry gauze. Applying light pressure would cause less trauma and irritation to the tissues. The nurse would not massage the site since massaging can force medications into subcutaneous tissue. The nurse would avoid recapping the needle to prevent accidental needlestick injury.

After preparing the skin of a client's arm in preparation for an intradermal injection, how would the nurse insert the needle?

At a 5- to 15-degree angle, almost against the skin, bevel side up. Rationale: The nurse would hold the needle with the dominant hand at a 5- to 15-degree angle, almost against the skin, with the bevel side up. Having the bevel side up allows for the smooth piercing of the skin and introduction of medication into the dermis. The dermis is entered when the needle is held as nearly parallel to the skin as possible.

The nurse is preparing to administer two types of insulin by mixing in one syringe. What is the first action by the nurse?

Determine compatibility of the insulins by checking a drug compatibility table. Rationale: The first step in mixing two types of insulin in one syringe is verifying compatibility. Some insulins cannot be mixed together. The other steps are appropriate but should be completed after determining compatibility.

The nurse is holding the skin with the non-dominant hand prior to inserting the needle for an intramuscular injection. What is the recommended technique?

Displace the skin using the Z-track technique by pulling the skin to one side 1 inch. Rationale: For an intramuscular injection, the nurse would displace the skin using the Z-track technique, pulling the skin down or to the side about 1 inch. For an intradermal injection, the nurse would stretch the skin taut taking care not to touch the injection site. For a subcutaneous injection, the nurse would grasp and bunch the skin in the area surrounding the injection.

The nurse is preparing a local anesthetic to be administered intradermally to a client undergoing a minor surgical procedure. Which guideline is recommended for administering this injection?

Do not massage the site following administration. Rationale: Following an injection, the site should not be massaged, nor should pressure be applied. The nurse would clean the injection site with an antimicrobial swab. Used needles should not be recapped.

The nurse administering a subcutaneous injection to a client avoids massaging the site after injecting the medication. Why is massaging the site contraindicated?

It can damage underlying tissue. Rationale: Massaging the site following a subcutaneous injection is contraindicated because it is not necessary and might damage the underlying tissue or increase the absorption and possibly the potency of the medication. Massaging the site does not increases the risk for infection. Contamination of the needle or not cleaning the site increases the risk for infection

A nurse is giving a client an intradermal injection to perform a tuberculin test. In what layer of the skin are intradermal injections administered?

Just below the epidermis. Rationale: Intradermal injections are administered into the dermis, just below the epidermis. The epidermis is the first layer of the skin, the dermis is the second layer, and the subcutaneous tissue is the third layer.

The nurse assesses the client and checks the medication prescription prior to administering an intramuscular injection. Which factor affects the choice of an intramuscular site?

Medication volume. Rationale: The nurse should consider the age of the client, the medication type, and the medication volume when determining a site for an intramuscular injection. The gender of the client and diagnosis do not determine the site. The chosen site dictates what size of needle is used.

A nurse is administering an intramuscular injection to a client. Which best describes the nurse's recommended hand movements?

Moves non-dominant hand to steady the lower end of the syringe, and dominant hand to the end of the plunger. Rationale: When administering an intramuscular injection, the nurse should use the non-dominant hand to steady the lower end of the syringe, and the dominant hand should be on the end of the plunger. These movements help the nurse avoid moving the syringe.

The nurse is preparing a medication form a vial and notices that a piece of the self-sealing stopper is floating in the medication in the syringe. What should the nurse do next?

Obtain a new vial, syringe and needle and start over Rationale: If a piece of self- sealing stopper is floating in the medication, the nurse should obtain a new vial, syringe, and needle and begin again. The floating material is an indication of contamination. It would be harmful to a client to administer contaminated medication; therefore, all other responses are incorrec

What will the nurse do with the filter needle after withdrawing medication from an ampule?

Remove the filter needle and attach the administration needle. Rationale:Once the medication is in the syringe, the nurse would remove the filter needle from the syringe and attach a new administration needle. To prevent glass shards from contaminating the medication, this needle is not used to administer the medication or inject air into the medication. Filter needles are not used to administer medications to clients as the glass shards would cause injury. Filter needles should be discarded, not saved for later use.

The nurse is administering an intramuscular injection in the deltoid site when the client pulls away from the needle before the medication is fully injected. What should the nurse do next?

Replace the needle on the syringe and administer the remaining medication in another site. Rationale: If a client pulls away from the needle when administering an intramuscular injection, the nurse should remove and replace the needle and administer the remaining medication using a different injection site. The nurse should then document the event according to facility policy.

The nurse has just finished injecting a medication intramuscularly, and needle is still in the client's arm. Which is the correct immediate next step?

Wait 10 seconds and then withdraw the needle Rationale: The immediate next step would be to wait 10 seconds and then withdraw the needle. Waiting allows the medication to begin to diffuse into the surrounding muscle tissue. Aspiration, or pulling back on the plunger to check that a blood vessel has been entered, is not necessary nor recommended. Moving the syringe could cause damage to the tissues and inadvertent administration into incorrect area, so this should not be done.

When administering an intradermal injection, what sign will the nurse observe that indicates when to pull out the needle?

Wheal Rationale: The nurse would pull the needle out quickly at the same angle it was inserted when a small blister or wheal appears. This minimizes tissue damage and discomfort for the client.

What is the best way for the nurse to remove air bubbles from the syringe after drawing up medication from an ampule?

Withdraw the needle from the ampule, tap the syringe, and push on the plunger. Rationale:The best way to remove air bubbles from the syringe is to wait until the needle has been withdrawn to tap the syringe and expel the air carefully by pushing on the plunger.

How much air does the nurse inject into a vial prior to withdrawing the medication?

equal to the amount of the medication dosage Rationale: The nurse would draw back an amount of air into the syringe that is equal to the specific dose of medication to be drawn. Because a vial is a sealed container, before fluid is removed, injection of an equal amount of air is required to prevent the formation of a partial vacuum. If not enough air is injected, the negative pressure makes it difficult to withdraw the medication.

What actions assist to protect the client from infection when mixing medications from two vials in one syringe? Select all that apply.

touching the plunger of the syringe only at the knob Rationale: Performing hand hygiene is the first step in protecting a client form infection. Vigorously scrubbing the self-sealing top and allowing it to dry ensures that the antimicrobial has had time to be effective. Recapping the needle prevents contamination and touching only the knob of the plunger prevents contamination of the medication.

What is the best way for the nurse to hold a syringe when withdrawing 5 units from an insulin vial?

vertical and at eye level Rationale: The nurse would draw up the prescribed amount of medication while holding the syringe vertically and at eye level. Holding the syringe at eye level facilitates accurate reading, and the vertical position makes removing air bubbles from the syringe easier. Extending the arm forward may cause incorrect reading of the syringe.

The nurse is teaching a client to self-administer prescribed 15 units NPH insulin and 10 units regular insulin with breakfast. Which statement made by the client indicates a need for further teaching?

"If I withdraw more than 25 units into the syringe, it is okay for me to replace the medication in the vial and start again." Rationale: When mixing two insulins in the same syringe and the total dosage is incorrect, there is no way to know which medication dosage is incorrect or to separate the two medications. This syringe and medication should be discarded. Contamination of the plunger prior to withdrawing medication may cause contamination of the medication. When mixing two medications in a syringe it is important to ensure the medication vials are not contaminated.

The nurse is teaching a client with diabetes to withdraw insulin from a vial when the client and the client asks why it is recommended to recap the needle after withdrawing the medication. What is the best response by the nurse?

"Recapping the needle maintains sterility of the needle before injecting." Rationale: The needle should be recapped after withdrawing medication to maintain the sterility of the needle prior to injecting. Recapping the needle will not prevent medication from leaking out.

The nurse is preparing to administer a subcutaneous injection for an adult client. The nurse knows that the volume of the injection is limited to how many milliliters of fluid?

1 mL Rationale: The volume of fluid administered in a subcutaneous injection is usually limited to 1 mL for an adult client. Giving larger amounts adds to the client's discomfort and may lead to poor absorption of the medication.

The nurse has chosen the deltoid site to administer an intramuscular injection to an adult client. What size needle would the nurse use?

1 to 1 1/2 in (2.5 to 3.8 cm).

The nurse needs to prepare an insulin pen for injection of a prescribed dose of insulin. Place the following steps in the correct order. Use all options.

1)Clean the tip of the reservoir with alcohol. 2)Screw the correct needle onto the reservoir. 3)Dial the dose selector to 2 units. 4)Hold the pen upright and press the plunger firmly. 5)Watch for a drop of insulin at the needle tip. 6)Verify the dose selector returned to "0."

The nurse is preparing to draw up a medication that is supplied in a glass ampule. Place in order, the steps the nurse will take. Use all options.

1)Wrap a small gauze pad around the neck of the ampule. 2)Break off the top of the ampule. 3)Attach the filter needle to the syringe. 4)Withdraw the medication. 5)Discard the filter needle. 6)Attach a sterile administration device to the syringe.

The nurse is preparing supplies for a tuberculosis screening. The nurse should choose syringe and needle?

1-mL syringe; 1/2-inch, 27-gauge needle Rationale: Tuberculosis screening requires an intradermal injection. Equipment used for an intradermal injection includes a tuberculin syringe calibrated in tenths and hundredths of a milliliter and a 1/4- to 1/2-inch, 25- or 27-gauge needle. The dosage given intradermally is small, usually less than 0.5 mL.

The nurse is administering an intradermal injection to a client to test for allergies. How far would the nurse insert the needle into the dermis?

1/8 in (32 mm) with the entire bevel under the skin. Rationale: The nurse would insert the needle about 1/8 in (32 mm) with the entire bevel under the skin. The dermis is entered when the needle is held as nearly parallel to the skin as possible and inserted about 1/8 in (32 mm).

How quickly would the nurse inject solution into an intramuscular site?

10 sec/mL of medication. Rationale: When giving an intramuscular injection, the nurse would insert the needle and use the thumb and forefinger of the non-dominant hand to hold the lower end of the syringe and slowly inject the solution at 10 sec/mL of medication.

Which client would most likely be injected using an intradermal injection?

A client having an allergy test performed. Rationale: Intradermal injections have the longest absorption time of all parenteral routes. For this reason, intradermal injections are used for sensitivity tests, such as tuberculin and allergy tests, and local anesthesia. The body's reaction to substances is easily visible and degrees of reaction are discernible by comparative study. Insulin and morphine would most likely be administered subcutaneously or as an IV. Vaccinations are usually administered intramuscularly.

The nurse is demonstrating to a client with diabetes how to properly self-inject insulin. Which injection site would be most appropriate to recommend to the client?

Abdomen Rationale: The abdomen and anterior aspect of the thigh are common injection sites for subcutaneous injections. Sites commonly used for intradermal injections are the inner surface of the forearm and the upper back, under the scapula. The deltoid muscle of the shoulder is a common injection site for intramuscular injections.

The nurse is preparing a medication from a vial and contaminates the plunger after the medication is drawn into the syringe. What should the nurse do next?

Administer the medication as prescribed Rationale: The nurse should administer the medication as prescribed. It is not necessary to discard the syringe or medication and start over. A new plunger is not needed since the contaminated plunger will enter the barrel of the syringe when pushing the medication out and will not come into contact with the medication, therefore, it will not contaminate the medication.

The nurse has just finished administering the 0800-prescribed 10 units regular insulin in the left arm using an insulin injection pen. What will the nurse include in the documentation?

Administered 10 units regular insulin subcutaneous at 0800 in the left arm. Rationale: After the injection, the nurse should document the administration of the medication by noting that the client was given the medication, the dose, the time of administration, and the site where it was administered.

What is the correct procedure for preparing an insulin injection for a client who requires two types of insulin?

Check the drug administration book for insulin compatibility. Rationale: If the client requires two insulin injections, the nurse would check the drug administration book or compatibility table (not with the health care provider) to see if they are compatible before mixing them together in one syringe. Two separate syringes of insulin would be necessary if the drugs are not compatible; therefore, it is important to check the drug administration book for compatibility before choosing the syringe

The nurse is cleaning the injection site prior to administering an intradermal injection. What motion should the nurse use for this action?

Circular motion from the injection site outward. Rationale: The nurse would clean the injection site with an antimicrobial swab in a circular motion from the injection site outward and allow it to dry. Pathogens on the skin can be forced into the tissues by the needle. Moving from the center outward prevents contamination of the site.

The nurse is preparing to administer an intramuscular injection to a client. Which statement accurately describes how to prepare the client's skin prior to the injection?

Cleanse the area around the injection site with an antimicrobial swab using firm, circular motions moving outward from the site. Rationale: The nurse would cleanse the area around the injection site with an antimicrobial swab using firm, circular motions moving outward from the site. Moving from the inside to the outside prevents contamination of the site. The site does not need to be shaved or cleaned with soap and water.

Which is true about giving medication using the intramuscular route?

Delivers medication into the muscle tissues. Rationale: Giving medication using the intramuscular route delivers the medication directly to the muscle tissues. These tissues have bigger blood vessels, and more of them, than subcutaneous tissue. This allows for a faster onset of the medication.

The nurse is preparing to administer NPH insulin 10 units and regular insulin 5 units by mixing in the same syringe. What is the best way to prevent contamination of the regular insulin with the NPH insulin?

Inject 10 units of air into the space above the NPH insulin followed by injecting 5 units of air into the space above the regular insulin Rationale: Placing air in the NPH insulin first without allowing the needle to contact the insulin ensures the second vial is not contaminated by the medication from the first vial. When mixing a modified insulin (suspension) with an unmodified insulin (clear), the unmodified insulin should be drawn into the syringe first. It is not advised to change needles, as most insulin syringes do not have a detachable needle.

The nurse is preparing to administer an allergy test via an intradermal injection. Which injection site would be most appropriate in this situation?

Inner surface of the forearm Rationale: Sites commonly used for intradermal injections are the inner surface of the forearm and the upper back, under the scapula. The deltoid muscle of the shoulder is a common injection site for intramuscular injections. The abdomen and anterior aspect of the thigh are common injection sites for subcutaneous injections.

The nurse has a prescription to administer a tuberculin test for a client. On what body site would the injection be administered?

Inner surface of the forearm. Rationale: Common sites to administer intradermal injections are the inner surface of the forearm or the upper back, under the scapula. The deltoid muscle is used for intramuscular injections, and the abdomen and thigh are used for subcutaneous injections.

The nurse is preparing to administer a subcutaneous injection of insulin to a client. Which site would the nurse choose?

Outer aspect of the upper arm. Rationale: The nurse would administer a subcutaneous injection in the following sites: outer aspect of the upper arm, abdomen from below the costal margin to the ileac crests, the anterior aspects of the thigh, the upper back, or the upper ventrogluteal area.

A nurse is mixing two different types of insulin in one syringe. What is the next step after drawing the first insulin dose into the syringe?

Perform the third check by rechecking the medication label with the medication administration record. Rationale: After mixing two insulins in one vial, there is no way to ensure the accuracy of both doses of insulin. That is why it is important to recheck the medication administration record to make sure the dose of the first insulin is accurate before adding the second insulin dose. Injecting air into the second vial should be done prior to withdrawing the first dose of insulin. Calculating the endpoint and adding the second insulin would happen after performing a third check.

The nurse is administering an intramuscular injection of the hepatitis B vaccine to a client. At what angle would the nurse insert the needle?

Perpendicular to the skin. Rationale: When administering an intramuscular injection, the nurse would insert the needle perpendicular to the skin. Inserting the needle at a 90-degree angle facilitates entry into the muscle tissue.

The nurse is administering an intramuscular injection to a client using the ventrogluteal site. How would the nurse locate the site?

Place the palm on the greater trochanter and the index finger on the anterior superior iliac spine. Rationale: The nurse would locate the ventrogluteal site for intramuscular injection by placing the palm on the greater trochanter and the index finger on the anterior superior iliac spine. The injection site is between the index and middle finger.

The nurse is preparing to administer a vaccination to an adult in the deltoid site. In what position would the nurse place the client?

Sitting. Rationale: When administering an intramuscular injection to an adult in the deltoid site, the nurse may place the client in a sitting or standing position. The adult client may sit or lie supine for a vastus lateralis site injection. For a ventrogluteal site injection, the client may stand, sit, or lie laterally or supine.

The nurse is withdrawing insulin from a vial to prepare an injection for a client. After removing the metal cap on the vial, what would be the nurse's next step in the procedure?

Swab the rubber top with an antimicrobial swab and allow it to dry. Rationale: When withdrawing medications from a vial, the nurse would remove the metal or plastic cap protecting the rubber stopper, swab the rubber top with an antimicrobial, and allow it to dry. The nurse would then inject air into the rubber cap with the needle tip while holding the vial on a flat surface.

The nurse is teaching the student nurse where a subcutaneous injection is administered. How would the nurse describe the appropriate skin layer?

The adipose tissue layer, just below the epidermis and dermis. Rationale: A subcutaneous injection is given into the adipose tissue layer. An intradermal injection is given in the tissue known as the dermis. An intramuscular injection is given in the tissue comprising the muscles.

The nurse has just finished administering an insulin pen injection on a client and documents the administration in the electronic health record. Which is the correct information to document?

The fact that the medication was given, the dose and the time, and the site. Rationale: After the injection, the nurse should document the administration of the medication by noting that the client was given the medication, the dose, the time of administration, and the site where it was administered.

Which is most important to document when mixing medications from two vials in one syringe?

Time of administration Rationale:When documenting administration of medications, it is important to document the medication, dose, route, and time administered. It is not important to document the methods for removing the medication or the type of syringe.

The nurse administering an intramuscular injection to a client divides the thigh into thirds, horizontally and vertically to locate the site. What injection site is the nurse using?

Vastus lateralis site. Rationale: The vastus lateralis site is located by dividing the thigh into thirds, horizontally and vertically. The ventrogluteal site is located by placing the palm on the greater trochanter and the index finger on the anterior superior iliac spine. The deltoid muscle is located by placing 2 to 3 fingers below the lower edge of the acromion process. The greater trochanter of femur is part of the ventrogluteal site.

What is the best method for opening an ampule of morphine for a prescribed IV push?

Wrap a small gauze pad around the neck and use a snapping motion to break the top at the scored line in the neck. Rationale:When opening an ampule, the nurse would use a small gauze pad or dry alcohol wipe to hold the top and use a snapping motion to break off the top of the ampule at the scored line. The pad protects the fingers from the glass as the ampule is opened. A twisting motion is not recommended. Applying pressure with a gloved hand to the top of the ampule will not effectively break the scored line at the neck.

The nurse is preparing to administer 10 units regular insulin via insulin injection pen to a client with a body mass index (BMI) equal to 40. How will the nurse best administer this medication?

at 90-degree angle using a 5/8-in (1.6-cm) needle Rationale: Injections using an insulin pen should be administered at a 90-degree angle using a needle appropriate for the client's body size. Subcutaneous injections normally use a 3/8- to 5/8- in (0.9- to 1.6-cm) needle. An obese client would require the longer needle size. Subcutaneous injection using an insulin syringe and needle would be given at a 45-degree angle.

A nurse is preparing a medication from a glass ampule. After breaking the ampule, the nurse notes blood on the gauze pad. What should the nurse do first?

discard the ampule and medication Rationale: Blood on the gauze pad indicates the nurse has been cut while opening the glass ampule. The nurse should first discard the ampule and medication in case contamination has occurred. The nurse would then clean and bandage the wound, and then obtain a new ampule and prepare a new dose, using a new gauze pad. After preparing a new dose of medication, it would be administered as prescribed. The injury should be reported as per facility policy.

A nurse is preparing the prescribed NPH insulin (isophane insulin suspension) 15 units and regular insulin 5 units in one syringe for subcutaneous administration. Which action by the nurse is correct?

injecting 15 units of air into the NPH insulin vial; then injecting 5 units of air into the regular insulin vial Rationale: After checking compatibility of two types of insulin, the nurse will first inject an equal amount of air into the insulin suspension and then an equal amount of air into the regular insulin. The nurse then draws the prescribed amount of regular insulin into the syringe and then adds the prescribed amount of insulin suspension to the syringe. This prevents contamination of the regular insulin with the insulin suspension. Equal amounts of air prevent a vacuum from forming in the vial.

What are important actions by the nurse to prevent infection when mixing two different types of insulin in the same syringe? Select all that apply.

perform hand hygiene, clean tops of multidose vials with alcohol before each entry, keep multidose vials assigned to single clients, use a new sterile needle and syringe before each entry Rationale: To prevent infection the US Centers for Disease Control and Prevention recommends that all multidose vials be assigned to a single client whenever possible. Cleaning the top of the vial with alcohol, using new sterile needles and syringes and performing hand hygiene are all means to prevent infection in clients by decreasing exposure to microorganisms. It is recommended to perform a third check of the medication at the bedside, but this would promote client safety, not prevent infection.