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 A
Explanation
Choice A reason: Flow rate is volume divided by time; 250 mL over 4 hours equals 62.5 mL/hr, ensuring safe transfusion pacing to avoid fluid overload or hemolysis.
Choice B reason: 125 mL/hr assumes 250 mL over 2 hours; this doubles the ordered rate, risking circulatory overload and transfusion reactions in a standard protocol.
Choice C reason: 250 mL/hr infuses the unit in 1 hour; this rapid rate exceeds safe limits, potentially causing hypertension or pulmonary edema in vulnerable patients.
Choice D reason: 500 mL/hr is far too fast, implying 250 mL in 30 minutes; this dangerous speed could trigger severe hemolytic reactions or cardiovascular collapse.
Correct Answer is D
Explanation
Choice A reason: Blood pressure matters but isn’t primary; opioids rarely cause acute hypotension initially, and respiratory depression is a more immediate life-threatening risk.
Choice B reason: Temperature is unrelated; opioids don’t primarily affect fever, and this assessment doesn’t address the critical safety concern of opioid administration.
Choice C reason: Pulse is secondary; opioids may slow heart rate mildly, but respiratory suppression is the urgent risk, requiring priority monitoring before dosing.
Choice D reason: Respiratory rate is critical; opioids depress the brainstem, risking apnea, and assessing breathing ensures safety before administering this high-risk medication.
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.