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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Drawing at 8:30 a.m., 60 minutes before, is too early; trough levels, taken just before the next dose, reflect minimum concentration, and this timing risks inaccurate results.
Choice B reason: At 9:00 a.m., 30 minutes before the 9:30 a.m. dose, the trough level accurately measures the lowest vancomycin concentration, ensuring therapeutic monitoring aligns with pharmacokinetics.
Choice C reason: Drawing at 10:00 a.m., after the dose, measures a post-infusion level, not the trough; this timing misses the minimum concentration critical for dosing adjustments.
Choice D reason: At 10:30 a.m., well after the dose, blood reflects peak or random levels, not the trough, skewing data needed to assess vancomycin’s therapeutic efficacy and safety.
Correct Answer is B
Explanation
Choice A reason: Checking with another nurse may occur, but it’s not mandatory for all schedule II drugs; documentation is the primary legal responsibility to track controlled substances accurately.
Choice B reason: Signing out on a narcotic sheet is required; schedule II drugs like opioids need strict tracking to prevent diversion, ensuring accountability per federal and hospital regulations.
Choice C reason: Leaving medication at the bedside violates security; schedule II drugs must remain controlled, as unattended narcotics risk theft or misuse, breaching safety protocols entirely.
Choice D reason: Extra water is irrelevant to responsibility; it’s a hydration tip, not a legal or safety duty tied to administering highly regulated schedule II controlled substances.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.