- The nurse is preparing to draw medication from a glass ampule. After breaking the neck of the ampule, what is the next step?
Answer: Use a filter needle to withdraw the medication.
When an ampule is opened, there is a risk of microscopic glass shards entering the solution. A filter needle must be used to withdraw the medication to prevent these particles from being drawn into the syringe and injected into the client. Air is not injected into an ampule, as it is an open system. Wiping the broken edge is not necessary and could introduce fibers into the medication.
- The nurse is preparing to withdraw medication from a multi-dose vial for the first time. After cleansing the rubber stopper, what is the next action?
Answer: Inject an amount of air into the vial equal to the dose to be withdrawn.
To withdraw medication from a vial without creating a vacuum, the nurse must first inject air into the vial. The amount of air injected should be equal to the amount of medication to be withdrawn. This equalizes the pressure inside the vial, making it easier to draw out the solution accurately. A filter needle is used for ampules, not typically for standard vials.
- The nurse is reinforcing teaching for a client with type 1 diabetes about subcutaneous insulin injection sites. Which statement by the client indicates a need for further teaching?
Answer: 'I will inject my insulin into my thigh right before I go for a long run.'
Injecting insulin into a limb that will be heavily exercised can cause the insulin to absorb more rapidly than usual, potentially leading to hypoglycemia. The client should be taught to avoid injecting into a muscle group that will be used extensively during exercise. The other statements demonstrate a correct understanding of insulin administration.
- The nurse is preparing to administer a prescribed antibiotic via IV piggyback to a client with a stable, existing peripheral IV line. Which action is essential before starting the infusion?
Answer: Check for compatibility between the antibiotic and the primary IV fluid.
Before administering an IV piggyback medication, it is critical to verify the compatibility of the secondary medication with the primary IV solution. If the solutions are incompatible, a precipitate could form, clogging the IV line and potentially causing an embolus. This is a crucial safety check. Flushing with heparin is not standard for peripheral IVs, and a new line is unnecessary if the current one is patent and the fluids are compatible.
- The nurse is using the Z-track method to administer an intramuscular injection of iron dextran. What is the primary purpose of this technique?
Answer: To prevent medication from leaking into subcutaneous tissue.
The Z-track method involves pulling the skin and subcutaneous tissue to the side before injection, then releasing it after the needle is withdrawn. This creates a zigzag path that seals the medication deep within the muscle, preventing it from leaking back into the subcutaneous tissue and skin, which is especially important for irritating medications like iron.
- The practical nurse is preparing to administer a vitamin K injection to a newborn. Which injection site is the safest and most appropriate choice?
Answer: Vastus lateralis muscle of the thigh
The correct site is the vastus lateralis muscle of the thigh. This muscle is well-developed at birth, located on the anterolateral aspect of the thigh, and is free of major nerves and blood vessels, making it the safest IM injection site for a newborn. The deltoid muscle of the shoulder is underdeveloped in newborns and is not used for intramuscular injections until later childhood. The ventrogluteal muscle of the hip is also underdeveloped in infants and is not recommended for newborn injections. The dorsogluteal muscle of the buttock is not recommended for any patient due to the risk of sciatic nerve injury, and the gluteal muscles are immature in newborns. Therefore, the vastus lateralis is the only site that meets the safety and appropriateness criteria for this injection.
- The nurse needs to reconstitute a powdered medication in a multi-dose vial. After injecting the correct amount of diluent, what is the next action?
Answer: Roll the vial gently between the hands.
To ensure the powdered medication dissolves completely without being damaged, the vial should be rolled gently between the palms. Shaking the vial vigorously can create excessive foam or denature the protein in certain medications, rendering them ineffective. The vial should be labeled after reconstitution is complete and before it is stored or used.
- Which action should the nurse take FIRST?
Answer: Stop the infusion and remove the catheter.
The client's signs and symptoms (pain, pallor, coolness, swelling) are classic indicators of IV infiltration, where the IV fluid is leaking into the surrounding tissue. The first and most important action is to stop the infusion immediately to prevent further fluid from entering the tissue and causing more damage. After stopping the infusion, the nurse should remove the catheter, elevate the limb, and notify the RN.
- The nurse is administering a subcutaneous injection of heparin. Which action by the nurse is correct?
Answer: Injecting into the abdominal tissue 2 inches from the umbilicus.
Heparin should be administered subcutaneously into the abdomen, at least 2 inches away from the umbilicus, to ensure proper absorption and avoid large blood vessels. Massaging the site can cause bruising and is contraindicated. Aspirating is not necessary for subcutaneous heparin and can increase tissue damage. A 1.5-inch needle is too long for a subcutaneous injection and would likely enter the muscle.
- The practical nurse responds to an IV infusion pump alarm indicating an occlusion. Which action should the nurse take first?
Answer: Check the IV tubing for kinks and assess the client's position.
When an occlusion alarm sounds, the nurse should start with the simplest, non-invasive assessments. The most common causes of occlusion are kinked tubing or the client's arm being bent at the IV site. Checking for and correcting these issues should be the first step. Flushing the line or increasing the rate without assessing could dislodge a clot or worsen an infiltration. The IV may not need to be restarted.
- A primary health care provider has prescribed a 1.5 mL intramuscular injection. The client prefers the injection in the arm. What is the nurse's most appropriate action?
Answer: Inform the client that the deltoid muscle is not recommended for this volume.
The deltoid muscle is a small muscle and should not receive more than 1 mL of medication per injection to avoid tissue damage and ensure proper absorption. The nurse's most appropriate action is to educate the client about this safety limitation and then proceed to select a larger, more appropriate site like the ventrogluteal muscle. Simply asking the client to choose without providing education is incomplete.
- The nurse is preparing to administer an IM immunization to an adult client who is obese. Which needle length is most appropriate for a ventrogluteal injection?
Answer: 1.5 inches
For an obese adult client, a longer needle is required to penetrate the adipose tissue and reach the muscle. A 1.5-inch needle is a standard and appropriate choice for an IM injection in the ventrogluteal site of an obese client. A 5/8-inch or 1-inch needle may deposit the medication into the subcutaneous tissue, while a 3-inch needle is typically excessively long unless the client is morbidly obese.
- What is the nurse's immediate priority?
Answer: Call for immediate assistance and notify the RN.
The client is exhibiting signs of anaphylaxis, a life-threatening allergic reaction. The LPN's immediate priority is to recognize this emergency and activate the facility's emergency response system or call for the RN and other help. This ensures the client receives rapid, advanced medical intervention. While documentation and medication administration are important, securing immediate help is the first and most critical action.
- A 63-year-old client with COPD is prescribed hydromorphone 0.2 mg IV push for severe post-operative pain. After administration, the client becomes difficult to arouse; RR 8/min, SpO2 86% on room air, BP 98/60. Which finding should be REPORTED immediately after medication administration?
Answer: RR 8/min with decreased level of consciousness
This question tests knowledge of parenteral medication administration and clinical judgment in opioid side effects. The key assessment finding after administration is RR 8/min with decreased consciousness, indicating overdose. Reporting the low RR with LOC change immediately is critical as it requires intervention like naloxone, aligning with safe practice. Pain reduction is expected; mild itching or repositioning requests are minor. The decision-making principle is rapid recognition of respiratory depression. Safety guidelines include continuous monitoring post-opioid. A transferable strategy is to have emergency protocols accessible for opioid-related events.
- A 66-year-old client is receiving gentamicin IV for a post-operative infection. Latest labs: BUN 38 mg/dL, creatinine 2.1 mg/dL (elevated from baseline 1.0); urine output 20 mL/hr. Which finding should be REPORTED immediately after medication administration?
Answer: Creatinine 2.1 mg/dL with decreased urine output
This question tests knowledge of parenteral medication administration and clinical judgment in aminoglycoside monitoring. The key assessment finding after administration is elevated creatinine with low urine output, signaling nephrotoxicity. Reporting the creatinine 2.1 mg/dL with decreased output immediately is critical as gentamicin can cause renal damage, aligning with safe practice. Mild nausea or temperature decrease is less urgent; intact IV site is positive but not the issue. The decision-making principle is to monitor renal function serially. Safety guidelines include holding for rising creatinine. A transferable strategy is to trend labs and output during ototoxic/nephrotoxic therapies.
- The nurse is discontinuing a peripheral intravenous catheter for a client who is not on anticoagulant therapy. What is the most important action for the nurse to take immediately after removing the catheter from the vein?
Answer: Check the catheter tip to ensure it is intact.
While applying pressure is a crucial step to prevent bleeding, the most critical safety action is to inspect the removed catheter tip to verify that it is intact. A broken catheter tip can become an embolus in the bloodstream, which is a medical emergency. After confirming the catheter is intact, the nurse should apply pressure to the site.
- After administering an intramuscular injection, the nurse is walking to the sharps container and drops the uncapped, used syringe on the floor. What is the nurse's best course of action?
Answer: Use tongs or forceps to place the syringe in the sharps container.
To prevent a needlestick injury from a contaminated sharp, the nurse should not use their hands to pick up the dropped syringe. The safest method is to use a mechanical device, such as forceps or tongs, to handle the syringe and dispose of it properly in the sharps container. Leaving it on the floor creates a hazard for others, and recapping a used needle is not recommended.
- The nurse is monitoring a client's peripheral IV site. Which finding would indicate the development of phlebitis?
Answer: A red streak along the vein.
Phlebitis is the inflammation of a vein. Classic signs include warmth, pain, tenderness, erythema (redness), and a palpable cord or red streak along the path of the vein. Coolness and pallor are signs of infiltration. Leaking fluid may indicate a loose connection or infiltration. Decreased skin turgor is not a localized sign related to phlebitis.
- The nurse is monitoring a client receiving IV fluids at 125 mL/hr. Which finding suggests fluid volume overload and requires immediate reporting to the RN?
Answer: Crackles in the lung bases
Crackles (rales) heard upon auscultation of the lungs are a sign of fluid in the alveoli (pulmonary edema), which is a serious complication of fluid volume overload. This is an abnormal finding that indicates the client's circulatory system is overwhelmed and requires immediate intervention. The other findings are within normal limits or suggest dehydration.
- A 5-year-old child with type 1 diabetes received insulin lispro subcutaneous with lunch. One hour later the child becomes irritable and sleepy; capillary blood glucose is 49 mg/dL; HR 124, RR 24. Which finding should be REPORTED immediately after medication administration?
Answer: Blood glucose 49 mg/dL with behavior change
This question tests knowledge of parenteral medication administration and clinical judgment in monitoring rapid-acting insulin. The key assessment finding after administration is blood glucose of 49 mg/dL with irritability and sleepiness, indicating hypoglycemia. Reporting the low glucose with behavior change immediately is critical as it requires urgent treatment, aligning with safe practice. Requesting a snack or mild hunger is normal; a small bruise is minor and expected. The decision-making principle is to recognize post-administration hypoglycemia symptoms promptly. Safety guidelines include glucose checks after insulin. A transferable strategy is to educate on hypoglycemia signs and monitor closely after doses.
