A nurse is assessing a patients continuous infusion and notices swelling, pallor, and comes at the infusion site What is the nurse's first action?

A. Pull the skin laterally with the non-injecting hand and maintain this position until the needle is withdrawn slowly, and release the skin slowly: The Z-track technique displaces subcutaneous tissue to create a zigzag path, preventing medication from leaking into subcutaneous tissue. Maintaining lateral tension during injection and slow withdrawal ensures proper deposition and minimizes tissue irritation.

B. Pull the skin taut with the forefinger and thumb of the non-dominant hand before needle insertion: Pulling the skin taut is not part of the Z-track method and does not create the necessary tissue displacement. This technique is more appropriate for standard intramuscular injections without irritant medications.

C. Release the displaced skin quickly before removing the needle to minimize skin trauma: Releasing the skin before needle withdrawal would allow medication to track back into subcutaneous tissue, increasing irritation and tissue staining. Maintaining tension until withdrawal is critical.

D. Massage the injection site vigorously after needle withdrawal to disperse the medication and reduce pain: Massaging an irritant IM injection site can worsen tissue damage, cause staining, and increase discomfort. The Z-track technique is designed to prevent the need for post-injection massage.

A. Holds many responsibilities: The nurse is responsible for safely preparing, verifying, administering, and monitoring medications. This includes assessing the client’s condition, identifying potential contraindications, observing for adverse effects, and documenting accurately. The nurse must also educate the client and respond promptly to any complications.

B. Has very few responsibilities: Medication administration carries significant responsibilities for safety, accuracy, and client monitoring. Minimizing the nurse’s role would compromise patient care and increase the risk of errors.

C. Delegates all tasks to other personnel because she is too busy: While certain support tasks can be delegated, the nurse cannot delegate the assessment, verification, administration, and monitoring of medications. These are critical responsibilities that require professional judgment.

D. Only prepares medications: Preparing medications is only one part of the nurse’s role. Safe administration also requires verification, monitoring, documentation, and client education, which go beyond mere preparation.