Which is the priority action of the nurse immediately after administration of an intramuscular injection?

Inform the patient that the injection is complete.

Assess the patient's level of comfort.

Engage the safety sheath over the needle.

Ensure that there is no bleeding at the injection site.

Answer and Explanation

The Correct Answer is C

Choice A reason: Informing the patient is secondary; it addresses communication but not immediate safety risks like needlestick injury, which is a higher priority post-injection per occupational health standards.

Choice B reason: Assessing comfort is important but not urgent; pain evaluation can wait after securing the needle, as safety from sharps exposure outweighs immediate patient feedback in priority.

Choice C reason: Engaging the safety sheath prevents needlestick injuries; it’s the priority action to protect the nurse and others from bloodborne pathogens, aligning with universal precautions post-injection.

Choice D reason: Checking for bleeding is routine but not critical; minor oozing is common and manageable later, while needle safety is an immediate concern to prevent infection risks.

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Correct Answer is A

Explanation

Choice A reason: Blood indicates vascular entry; discarding prevents unintended IV delivery of an IM drug, avoiding rapid absorption risks and ensuring proper route administration.

Choice B reason: Giving with blood risks IV administration; IM drugs aren’t formulated for this, potentially causing embolism or toxicity, violating safety administration principles.

Choice C reason: Changing the needle leaves contaminated medication; blood-mixed drugs are unsafe, and this fails to address the compromised dose integrity fully.

Choice D reason: Omitting skips treatment needlessly; the issue is procedural, not the order, and restarting ensures the patient receives the intended therapy safely.

A. 5 mL B. 7 mL C. 10 mL D. 14 mL

Correct Answer is B

Explanation

Choice A reason: 5 mL gives 125 mg; this underdoses the 175 mg order, reducing Ceclor’s antibacterial effect, risking persistent ear infection due to insufficient concentration.

Choice B reason: 7 mL is correct; 175 mg divided by 125 mg/5 mL equals 7 mL, delivering the exact cephalosporin dose for effective otitis media treatment.

Choice C reason: 10 mL provides 250 mg; this overdoses Ceclor, risking gastrointestinal upset or resistance, exceeding the therapeutic need for the infection safely.

Choice D reason: 14 mL yields 350 mg; this extreme overdose amplifies side effects like diarrhea or toxicity, far beyond the ordered 175 mg dose requirement.

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Which is the priority action of the nurse immediately after administration of an intramuscular injection?

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Naxlex Comprehensive Predictor Exams

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