Chapter 37 Fundamentals of Nursing

A group of nursing students are reviewing proper technique for administration of injections. Which medications do not require aspiration as part of the administration process? Select all that apply.

A. Insulin This is correct. Insulin injections should not be aspirated. B. Heparin This is correct. Heparin injections should not be aspirated. C. Flu vaccine This is correct. The CDC and ACIP highlight the importance of not aspirating for IM and subcut immunizations and vaccines in the health-care setting.

Which priority safety steps should the nurse take prior to administering a heparin injection? Select all that apply.

Have two other nurses verify the strength and dosage. This is correct. Heparin can be life-threatening if given in the wrong dose, so a second and third nurse must verify the correct dose. Assess PT, INR, and APTT results. This is correct. The nurse should monitor and assess the patient's laboratory results prior to administration of heparin. Perform medication check at least 4 times. This is correct. After checking the heparin label against the medication administration record three times, check it again.

A nursing student is reviewing the concept of first-pass metabolism. For a critically ill patient, which medication route would be preferred based on this concept?

The correct answer is: Parenteral

A nurse is preparing to reconstitute a medication in a multiple-dose vial. What is the most essential step in this process?

The correct answer is: Instilling the accurate amount of diluent into the vial

A nurse is using a prefilled syringe to administer a patient's medication. Which action should not be included in the administration process?

C. Recap once administered. This is correct. Safety: Do not recap the needle.

A nurse is monitoring a diabetic patient who has a fingerstick glucose level of 450 mg/dL. What is the next action the nurse should take?

Contact health-care provider (HCP). This is correct. A blood sugar level above 350 mg/dL typically requires contacting the HCP for orders.

Place the following steps of withdrawing medication from a vial in the order in which a nurse would appropriately perform them (1 to 6). (Enter the number of each step in the proper sequence without spaces. Do not use commas.)

Feedback: The nurse should wash hands before handling medication and equipment. The nurse should wipe the rubber stopper of the vial with an alcohol wipe and pull the plunger back, filling the syringe reservoir with air equal to the amount of solution to be drawn up. Then the nurse should pierce the rubber stopper of the medication vial at a 90-degree angle. The nurse should keep the needle tip above the fluid level while slowly injecting the air from the syringe into the air space above the medication in the vial. Finally, the nurse should invert both the vial and the syringe and carefully draw up the appropriate volume of medication.

A nurse is reviewing mixing of insulin preparations. Which subcutaneous medication order requires immediate action?

Lantus insulin 12 units with NPH 2 units

A patient has received a purified protein derivative (PPD) test. Which findings indicate a negative response? Select all that apply.

No blisters are present. This is correct. If blisters are present, they also indicate a positive result.

A nursing instructor is observing actions of nursing students in the laboratory setting as they prepare to administer an intramuscular injection. Which observation warrants immediate action?

Student pulls off the needle cover with their teeth. This is correct. Never use your teeth to pull off a needle cover.

A nurse is providing care for a 32-year-old with suspected bowel obstruction who is receiving intramuscular injections of narcotic pain medication. The patient states, "I hate shots. Why can't I just take a pill?" How should the nurse best respond?

The correct answer is: "We want to avoid giving you medication that you have to digest

A nurse is reviewing an order for administration of medication via subcut route. Which finding indicates that the nurse should contact the health-care provider (HCP) for clarification?

The correct answer is: 5 mL of solution is to be administered.

A nurse is preparing to provide an intramuscular injection to a newborn patient. Which priority information should the nurse include in the preparation for this skill?

The correct answer is: Do not use multiple-dose normal saline vials as diluent.

A nursing student is practicing how to administer injections in the clinical simulation lab. Which finding indicates that additional instruction is needed?

The correct answer is: Place syringe on counter after removing from packaging.

Which of the following is considered an essential step for the nurse to follow while withdrawing medication from an ampule?

The correct answer is: Using a filtered needle to withdraw medication

For which medications are a two-nurse verification system required before administering? Select all that apply.

The correct answers are: Heparin infusion adjustment, Heparin subcut, Insulin subcut

While injecting insulin into the patient, the nurse rotates injection sides around the abdomen. Which is the nurse trying to prevent? Select all that apply.

The correct answers are: Lipoatrophy, Lipohypertrophy

Under the appropriate supervision of the RN, the LPN/LVN is teaching a 40-year-old patient how to self-administer insulin. The patient also has impaired vision. Which actions are appropriate for this patient? Select all that apply.

The correct answers are: Obtain small insulin syringes that the patient can use to draw up the insulin., Demonstrate how to inject a volume of air into insulin prior to removing insulin., Let the patient practice rolling a vial of insulin.

A patient is on intravenous heparin therapy. Which lab parameters indicate that treatment has been effective? Select all that apply.

The correct answers are: PT 125 seconds, APTT 80 seconds

A nurse is preparing to administer an intramuscular injection to a patient who voices apprehension over having to get a shot. What strategies can the nurse use to increase patient comfort? Select all that apply.

The correct answers are: Prepare injection outside of patient's view., Change needle after drawing up medication., Inject the solution slowly., Engage the patient in conversation.

As the nurse is giving an intramuscular injection, blood is retuning into the syringe with aspiration. Which actions should the nurse take? Select all that apply.

The correct answers are: Withdraw the needle., Dispose of the medication-filled syringe., Try again with a new dose and needle.

A student nurse is preparing to provide 25 mg meperidine IM for pain. The medication cart is loaded with prefilled 50 mg meperidine syringes. The supervising nurse appropriately intervenes if the student nurse does which of the following?

answer is: Recaps the needle after the injection

A student nurse is practicing how to open up an ampule in the clinical simulation lab. Which action requires immediate intervention?

answer is: Uses bare hand to snap off ampule

A nurse is preparing to administer an intramuscular injection to a patient. Which findings if noted on the patient's medication profile should alert the nurse to potential bleeding? Select all that apply.

correct answers are: St. John's wort, Vitamin C, Omega 3 fatty acids