A nurse is observing a newly licensed nurse prepare a medication from an ampule for a client's injection. For which of the following actions by the newly licensed nurse should the nurse intervene?
Withdraws the medication from the ampule using a subcutaneous needle
Breaks the top of the ampule using an antiseptic wipe
Disposes of the ampule by placing it in a sharp’s container
Performs 3 checks of the medication before administration
The Correct Answer is A
Choice A Reason:
Withdraws the medication from the ampule using a subcutaneous needle is the correct answer. Medication from an ampule should be withdrawn using a filter needle or a needle specifically designed for ampule use, not a subcutaneous needle. Using the wrong type of needle can lead to contamination or injury to the nurse or the client.
Choice B Reason:
Breaks the top of the ampule using an antiseptic wipe is incorrect answer. Breaking the top of the ampule using an antiseptic wipe helps maintain sterility during the process. It is a standard practice to wipe the neck of the ampule with an antiseptic wipe before breaking it open to reduce the risk of contamination.
Choice C Reason:
Disposes of the ampule by placing it in a sharp’s container is incorrect answer. Disposing of the used ampule in a sharp’s container is the appropriate method for safe disposal of sharps to prevent needlestick injuries.
Choice D Reason:
Performs 3 checks of the medication before administration is incorrect answer. Performing three checks of the medication before administration is a standard safety practice to ensure accuracy and prevent medication errors. This includes checking the medication label against the medication administration record (MAR) or prescription, checking the medication against the MAR or prescription while preparing it, and checking the medication again before administering it to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Withdraws the medication from the ampule using a subcutaneous needle is the correct answer. Medication from an ampule should be withdrawn using a filter needle or a needle specifically designed for ampule use, not a subcutaneous needle. Using the wrong type of needle can lead to contamination or injury to the nurse or the client.
Choice B Reason:
Breaks the top of the ampule using an antiseptic wipe is incorrect answer. Breaking the top of the ampule using an antiseptic wipe helps maintain sterility during the process. It is a standard practice to wipe the neck of the ampule with an antiseptic wipe before breaking it open to reduce the risk of contamination.
Choice C Reason:
Disposes of the ampule by placing it in a sharp’s container is incorrect answer. Disposing of the used ampule in a sharp’s container is the appropriate method for safe disposal of sharps to prevent needlestick injuries.
Choice D Reason:
Performs 3 checks of the medication before administration is incorrect answer. Performing three checks of the medication before administration is a standard safety practice to ensure accuracy and prevent medication errors. This includes checking the medication label against the medication administration record (MAR) or prescription, checking the medication against the MAR or prescription while preparing it, and checking the medication again before administering it to the client.
Correct Answer is D
Explanation
Choice A Reason:
White blood cell count (WBC) is incorrect. Melena, which is the passage of black, tarry stools, is typically associated with upper gastrointestinal bleeding rather than an infection. While changes in WBC count might occur in response to infection or inflammation, it is not the primary laboratory test to monitor in response to melena.
Choice B Reason:
Glucose is incorrect.
Glucose monitoring is important for assessing blood sugar levels, particularly in diabetic patients or those at risk of hypoglycemia or hyperglycemia. However, it is not directly related to the presence of melena, which indicates gastrointestinal bleeding.
Choice C Reason:
Blood urea nitrogen (BUN) is incorrect. Blood urea nitrogen (BUN) levels can indicate renal function and hydration status, but they are not specifically related to the presence of melena. Monitoring BUN may be relevant in other clinical contexts, such as assessing kidney function or dehydration, but it's not the primary laboratory test to monitor in response to melena.
Choice D Reason:
Hematocrit is correct. Melena indicates upper gastrointestinal bleeding, which can lead to a significant loss of blood. Monitoring the hematocrit level is crucial in this context because it helps assess the severity of bleeding and guide appropriate interventions such as blood transfusions if necessary. A decrease in hematocrit indicates a decrease in the volume of red blood cells, which reflects blood loss and the need for further evaluation and management.
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