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

Performs 3 checks of the medication before administration

Disposes of the ampule by placing it in a sharps container

Answer and Explanation

The Correct Answer is A

A.   Withdrawal of medication from an ampule should be done using a filter needle or a needle with a filter straw to prevent glass particles from being drawn into the syringe. Using a subcutaneous needle is not appropriate for this purpose and may lead to contamination or injury.
B.   Breaking the top of the ampule using an antiseptic wipe is an acceptable method to access the medication within the ampule.
C.   Performing 3 checks of the medication before administration is a standard safety practice to ensure the correct medication, dose, and route.

D.   Disposing of the ampule by placing it in a sharps container is the correct method for safe disposal of glass ampules after use.

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Correct Answer is A

Explanation

A. Discuss the issue with the AP: This is the correct answer. Addressing the issue directly with the AP allows for immediate clarification of expectations and correction of behavior. It also provides an opportunity to understand any factors contributing to the deviation from protocol.
B. Reinforce facility protocols at the next staff meeting: While reinforcing facility protocols is important, addressing the issue directly with the individual involved should be the first step to ensure timely resolution and prevent further occurrences.
C. Notify the unit manager about the incident: Notifying the unit manager may be necessary if further action is required or if the issue cannot be resolved at the staff level. However, addressing the issue directly with the AP should be the initial step.
D. Alert the infection control department: Involving the infection control department may be necessary if there are concerns about potential infection control risks. However, discussing the issue with the AP allows for immediate action and clarification of expectations.

A. Reposition the client frequently. B. Instruct the client to use the incentive spirometer. C. Increase the amount of time the client spends out of bed each day. D. Ensure the client consumes an adequate amount of fluids.

Correct Answer is B

Explanation

A. Reposition the client frequently: While repositioning is important for preventing pressure ulcers and maintaining comfort, it may not be the priority immediately postoperatively compared to other interventions.
B. Instruct the client to use the incentive spirometer: This is the correct answer. Incentive spirometry helps prevent atelectasis and respiratory complications postoperatively, making it a priority intervention to include in the plan of care.
C. Increase the amount of time the client spends out of bed each day: Early ambulation is important for preventing complications such as deep vein thrombosis and pneumonia, but it may not be the priority immediately postoperatively depending on the client's condition and surgical procedure.
D. Ensure the client consumes an adequate amount of fluids: While hydration is important for postoperative recovery, ensuring adequate fluid intake may not be the priority compared to interventions aimed at preventing respiratory complications such as atelectasis.

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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?

Nursing Test Bank

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