A nurse is preparing to administer a medication from an ampule.
Which of the following is an appropriate action for the nurse to take?

Inject air into the ampule prior to drawing the medication into a syringe.

Add 0.5 mL of diluent to the medication.

Use a filter needle to aspirate the medication.

Cleanse the tip of the ampule with an alcohol swab after opening.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Injecting air into the ampule prior to drawing the medication into a syringe is incorrect because ampules are sealed glass containers, and injecting air could cause the liquid to spill out due to pressure changes.

Choice B rationale

Adding 0.5 mL of diluent to the medication is not appropriate for most medications in ampules unless specifically instructed by the medication guidelines. Ampules typically contain ready-to-use medication.

Choice C rationale

Using a filter needle to aspirate the medication is the correct action. A filter needle is used to prevent any glass particles from being drawn into the syringe, ensuring the medication is safe for administration.

Choice D rationale

Cleansing the tip of the ampule with an alcohol swab after opening is unnecessary because the ampule's contents are sterile and the risk of contamination is minimized if the ampule is handled correctly.

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Correct Answer is C

Explanation

Choice A rationale

Documenting the refusal in the client's medical record is important for legal and clinical reasons, ensuring there's a record of the client's decision and the nurse's response. However, it doesn't address the client's immediate concerns or needs.

Choice B rationale

Returning the medication to the medication cabinet is a necessary step to ensure medication safety and avoid accidental administration. Yet, it does not address the client's reasons for refusal or the potential risks involved.

Choice C rationale

The nurse’s first action should be to provide client education about the importance of taking the medication and the potential consequences of refusal (e.g., increased blood pressure, risk of stroke or heart attack). Addressing the client’s concerns about side effects can encourage adherence or lead to an alternative treatment plan.Client autonomy is respected, but ensuring informed refusal is part of the nurse’s role.

Choice D rationale

The provider should be informed, but only after the nurse has attempted to educate and address the client’s concerns. The provider may adjust the prescription if side effects are problematic.

A. Administer a sedative medication to the client. B. Explain to the client that they cannot leave until the surgeon discharges them. C. Have the client sign an against medical advice form. D. Tell the client that the surgeon will prescribe restraints if they try to leave.

Correct Answer is C

Explanation

Choice A rationale

Administering a sedative medication to the client without their consent is unethical and can constitute medical malpractice.

Choice B rationale

Explaining to the client that they cannot leave until the surgeon discharges them is not effective if the client insists on leaving against medical advice.

Choice C rationale

Having the client sign an against medical advice form is the appropriate action to document that the client understands the risks of leaving and is choosing to do so against the medical team's recommendations.

Choice D rationale

Telling the client that the surgeon will prescribe restraints if they try to leave is coercive and not an appropriate method to manage a client's desire to leave the hospital.

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A nurse is preparing to administer a medication from an ampule.Which of the following is an appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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A nurse is preparing to administer a medication from an ampule.
Which of the following is an appropriate action for the nurse to take?