A nurse is assessing a client who has a peripheral IV with a continuous infusion. Which of the following findings is a manifestation of phlebitis? (Select all that apply)(Select All that Apply.)

A. A client received gentamicin intermittent IV bolus over 1 hr:

While gentamicin is typically administered as an intermittent IV bolus, the rate of administration over 1 hour is not necessarily inappropriate. However, the specific institutional protocol or medication administration guidelines should be followed. If the rate of administration deviates significantly from the standard protocol or manufacturer's recommendations, it may warrant further investigation but may not necessarily require an incident report.

B. A nurse used a 25-gauge 3-inch needle to administer a heparin injection:

Using a 25-gauge 3-inch needle for heparin injection is not standard practice and may not be the most appropriate needle size for subcutaneous administration. However, it does not necessarily indicate a need for an incident report unless it resulted in harm to the client. It may prompt further education or clarification regarding appropriate needle selection for subcutaneous injections.

C. A nurse injected Demerol IM into the vastus lateralis site of an adult:

While Demerol (meperidine) is typically administered intramuscularly, the choice of the vastus lateralis site for injection in an adult may not be the most common practice, but it is an acceptable site for IM injections. Unless there are specific contraindications or adverse outcomes related to the site selection, this finding may not require an incident report. However, it could prompt a review of injection site selection guidelines or further education.

D. A client received a crushed bupropion XL tablet mixed with applesauce:

This finding indicates a need for an incident report. Bupropion XL (extended-release) tablets should not be crushed or chewed, as this can lead to rapid release and absorption of the medication, potentially causing adverse effects or toxicity. Administering crushed extended-release tablets is a medication error that warrants an incident report to document the event, assess potential harm to the client, and implement corrective actions to prevent recurrence.

When opening a glass ampule, it's essential to use the correct technique to prevent injury and ensure sterility. Here's the rationale for each option:

A. Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body: This technique is correct. Tapping the top of the ampule helps dislodge any medication that may be trapped in the neck. Placing a sterile gauze pad around the neck provides a barrier to protect against injury from glass shards. Breaking off the top by bending it toward the body helps prevent spillage of the medication.

B. Tap the bottom of the ampule, place a gauze pad around the ampule neck, and break off the bottom with a forward motion away from the body: Tapping the bottom of the ampule is unnecessary and may increase the risk of breakage. Breaking off the bottom with a forward motion away from the body is not the recommended technique for opening a glass ampule.

C. Wear sterile gloves and break off the neck of the glass ampule with a single snap in a downward motion: This technique does not involve the use of a gauze pad to protect against injury, which is essential for safe medication administration.

D. Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side: Breaking off the neck with a single snap to the right side is not a recommended technique. Additionally, using sterile gloves alone may not provide sufficient protection against injury from glass shards.