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A nurse administered ketorolac 30 mg IM to a client who is postoperative.
Which of the following information should the nurse document? (Select all that apply)

A.

Gauge and length of needle.

B.

Medication expiration date.

C.

Dose of medication administered.

D.

Site of injection.

E.

Time of administration.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:

The gauge and length of needle used for an IM injection are important to document. This information can help track which supplies were used and can be useful for future reference.

Choice B rationale:

While it’s important to check the medication expiration date before administration, it’s not typically documented after administering medication.

Choice C rationale:

The dose of medication administered should always be documented. This helps ensure accurate medical records and allows healthcare providers to track how much of a medication a patient has received.

Choice D rationale:

The site of injection should be documented. This can help prevent complications such as repeated use of the same injection site.

Choice E rationale:

The time of administration should be documented. This helps keep track of when the patient received their medication, which is crucial for medications that need to be given at specific intervals.


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Related Questions

Correct Answer is B

Explanation

Choice A rationale:

While a tuberculin syringe can be used for insulin administration, it’s not necessary when mixing NPH and regular insulin. Insulin syringes are typically used for this purpose.

Choice B rationale:

Injecting air into each vial before withdrawing insulin helps equalize pressure and makes it easier to draw up the insulin. This should be done before withdrawing any insulin.

Choice C rationale:

Withdrawing NPH insulin first contradicts the standard practice of drawing up insulins. The usual recommendation is to draw up short-acting (regular) insulin before intermediate-acting (NPH) insulin.

Choice D rationale:

Shaking the regular insulin vial is unnecessary and could potentially create bubbles, making it harder to draw up the correct dose of insulin.

Correct Answer is B

Explanation

Choice A rationale:

Hypernatremia (high sodium levels) is not a common side effect of spironolactone. Spironolactone is a potassium-sparing diuretic and does not typically affect sodium levels.

Choice B rationale:

Hyperkalemia (high potassium levels) is a potential adverse effect of spironolactone. As a potassium-sparing diuretic, spironolactone can cause an increase in serum potassium levels.

Choice C rationale:

Hypophosphatemia (low phosphate levels) is not typically associated with spironolactone use.

Choice D rationale:

Hypocalcemia (low calcium levels) is also not a common side effect of spironolactone.

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