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 C
Explanation
Choice A reason: An ID number alone lacks context; without name confirmation, it risks mismatching if wristbands are swapped, missing a critical identity check.
Choice B reason: Name alone may coincide with common names; without a unique identifier like a hospital number, this method risks errors in a busy unit.
Choice C reason: Name and hospital number provide dual identifiers; this matches the MAR precisely, ensuring accuracy for an unconscious patient per safety standards.
Choice D reason: Calling an unconscious patient is futile; they can’t respond, making this impractical and unreliable compared to objective wristband verification.
Correct Answer is D
Explanation
Choice A reason: Assuming patient preference lacks evidence; without asking, this dismisses autonomy, potentially misrepresenting the patient’s comfort with spiritual interventions.
Choice B reason: Endorsing without consent is inappropriate; the patient’s lack of affiliation suggests possible rejection, and this risks imposing unwanted religious activity.
Choice C reason: Doctor’s order isn’t required; prayer is a chaplain’s role, not medical, but patient consent is still needed, making this an unnecessary step.
Choice D reason: Permission respects autonomy; without religious affiliation, the patient may decline, and consent ensures ethical care aligned with individual beliefs.
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