While preparing to give an IM injection, the nurse aspirates and blood appears in the syringe.
The nurse should:
Withdraw the needle partially, redirect and reinsert it, and again aspirate, then administer the medication.
Withdraw the needle, discard the medication, and start over.
Administer the drug, but expect a small hematoma at the injection site.
Continue to administer the drug, just inject more slowly than usual.
The Correct Answer is B
Choice A rationale
Partially withdrawing and redirecting the needle after aspirating blood significantly increases the risk of tissue trauma, pain, and the formation of a hematoma at the injection site. Furthermore, there is a risk of inadvertently injecting medication into a blood vessel or the interstitial tissue, which could lead to complications such as nerve damage or localized irritation.
Choice B rationale
Aspirating blood indicates the needle tip has entered a blood vessel. Administering medication intravenously when an intramuscular injection is intended can have serious systemic consequences, including rapid absorption and potential adverse drug reactions or toxicity. Therefore, the safest action is to withdraw the needle, discard the contaminated medication, and prepare a new dose to ensure proper drug delivery.
Choice C rationale
Administering the drug despite aspirating blood significantly increases the risk of injecting the medication directly into a blood vessel (intravascular injection) rather than the muscle. This can lead to rapid systemic absorption, potentially causing adverse effects or toxicity, and may also result in a larger, more painful hematoma and delayed drug action.
Choice D rationale
Continuing to administer the drug after aspirating blood, regardless of the injection speed, is dangerous because it confirms the needle's placement within a blood vessel. Intravascular administration of an IM medication can lead to immediate systemic effects, allergic reactions, or drug overdose, bypassing the intended slower absorption rate of muscle tissue, and increasing risk of complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
The aortic valve is best auscultated at the second intercostal space (ICS) along the right sternal border. This anatomical landmark corresponds to the superficial projection of the aorta and is where the sounds of aortic valve closure and blood flow through the aorta are most clearly transmitted to the chest wall. Optimal sound transmission is achieved by minimizing intervening tissue. Pulmonic rationale:
The pulmonic valve is best auscultated at the third intercostal space (ICS) along the left sternal border, also known as Erb's point. While the pulmonic area is typically at the second ICS left sternal border, Erb's point provides a broader area for detecting murmurs related to both the pulmonic and aortic valves. This location provides good sound transmission for the pulmonary artery. Tricuspid rationale:
The tricuspid valve is best auscultated at the fourth intercostal space (ICS) along the left sternal border. This location overlies the right ventricle and the tricuspid valve, allowing for clear detection of its closure sounds and any associated murmurs. The proximity of the valve to the chest wall at this point facilitates optimal auscultation. Mitral rationale:
The mitral valve is best auscultated at the fifth intercostal space (ICS) at the midclavicular line (MCL). This location is also known as the apex of the heart, where the left ventricle's impulse is strongest. Sounds produced by the mitral valve, particularly during its closure, are best heard here due to the direct anatomical projection and maximal cardiac impulse. .
Correct Answer is C
Explanation
Choice A rationale
While method of administration is crucial, controlled substance schedule and identification are not universally required on every prescription. The core components for safe and effective medication administration are paramount for all prescriptions.
Choice B rationale
This choice omits the method of administration, which is vital for safe and effective drug delivery. Without this information, there is a risk of administering the medication incorrectly, potentially leading to adverse effects or lack of therapeutic benefit.
Choice C rationale
A complete prescription scientifically requires the drug name for identification, the dose to ensure therapeutic effect and prevent toxicity, the method of administration for correct delivery route, and the prescriber's signature for legal authorization and accountability.
Choice D rationale
Controlled substance schedules are specific to certain medications and identification is not a standard universal requirement on all prescriptions. The core components for general medication administration are the drug name, dose, method, and prescriber signature.
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