1
A nurse is administering a new medication to a patient for the first time. Which nursing actions demonstrate appropriate assessment for adverse effects? (Select all that apply.)
A. Monitor vital signs before and after administering the medication.
B. Observe the patient for signs of an allergic reaction, such as rash, itching, or swelling.
C. Ask the patient about any new symptoms, such as dizziness, nausea, or shortness of breath.
D. Assume no adverse effects will occur if the patient has taken the same medication in the past.
E. Document and report any unexpected changes in the patient’s condition immediately.
Correct Answers: A, B, C, E
Rationale:
Assessing for adverse effects is a critical nursing responsibility to ensure patient safety:
Monitor vital signs (A) to detect changes such as hypotension, bradycardia, or respiratory depression.
Observe for allergic reactions (B) including hives, rash, swelling, or respiratory distress.
Ask about new symptoms (C) because patients may experience nausea, dizziness, or other side effects.
Document and report (E) any unexpected reactions to the healthcare team for prompt intervention.
Option D: Never assume a medication is safe, even if previously tolerated, because adverse effects can develop at any time.
A nurse is preparing to administer a medication to a patient. Which of the following describes the correct sequence of the three medication administration checks?
A. Check the medication label against the MAR at the bedside → Draw up the medication and perform the second check → Check the medication against the MAR in the medication room.
B. Draw up the medication → Check the medication against the MAR at the patient’s bedside → Administer the medication.
C. Perform the third check at the medication room → Draw up the medication → Check the medication against the MAR at the bedside.
D. Check the medication against the MAR in the medication room → Draw up the medication and perform the second check → Perform the third check at the patient’s bedside.
Correct Answer is D. Check the medication against the MAR in the medication room → Draw up the medication and perform the second check → Perform the third check at the patient’s bedside.
Rationale:
The three medication administration checks are designed to prevent medication errors:
First check: Compare the medication against the MAR before removing it from the storage area to ensure the correct drug, dose, route, and time.
Second check: Perform the Six Rights check while preparing the medication (drawing up or pouring) to catch any errors before administration.
Third check: Perform the check at the patient’s bedside prior to administration to verify the right patient receives the correct medication.
This process ensures safety, accuracy, and compliance with nursing standards.
A nurse is preparing to administer ear drops to a 16-year-old patient. Which of the following actions demonstrates correct technique?
A. Position the patient supine or lateral, pull the pinna up and back, instill the medication, and have the patient remain in position for 5–10 minutes.
B. Pull the pinna of the ear down and back, insert the dropper, and instill the medication.
C. Have the patient sit upright, pull the pinna up and back, and instill the medication while standing.
D. Insert the dropper tip into the ear canal and instill the medication without pulling the pinna, as the pinna is only manipulated in children under 3 years old.
Correct Answer is A. Position the patient supine or lateral, pull the pinna up and back, instill the medication, and have the patient remain in position for 5–10 minutes.
🧠 Rationale:
For patients 3 years and older, including teenagers:
Position the patient supine or lateral to prevent spillage.
Pull the pinna up and back to straighten the external auditory canal.
Instill the prescribed number of drops and withdraw the dropper carefully.
Place a cotton ball if needed to retain medication and have the patient remain in position for 5–10 minutes to allow absorption.
Option B: Pulling the pinna down and back is correct only for children under 3 years old.
Option C: Upright positioning does not allow proper retention of the medication.
Option D: Not manipulating the pinna can prevent medication from reaching the canal effectively.
A nurse is preparing to administer a medication. Which of the following actions are part of the Six Rights of Medication Administration? (Select all that apply.)
A. Verifying the patient’s identity using two identifiers.
B. Checking the medication label against the MAR before administration.
C. Documenting the medication after it has been given.
D. Assessing the patient’s pain level before giving the medication.
E. Choosing the most convenient time to give the medication without consulting the MAR.
F. Ensuring the medication is given via the prescribed route.
Correct Answers: A, B, C, F
Rationale:
The Six Rights of Medication Administration ensure safe and accurate delivery of medications:
Right patient – verify identity using two identifiers.
Right drug – check the medication label against the MAR.
Right dose – confirm the correct amount.
Right route – give the medication via the prescribed route (oral, IM, IV, etc.).
Right time – administer at the correct time according to the provider’s order.
Right documentation – record the medication after it is given.
Option D: Assessing pain is important for nursing care but is not one of the Six Rights.
Option E: Giving medication at a convenient time without checking the MAR violates the right time and can be unsafe.
The nurse is preparing to withdraw medication from a glass ampule. Which action by the nurse indicates correct technique and promotes patient and nurse safety?
A. Injecting a small amount of air into the ampule before withdrawing the medication to equalize pressure
B. Using a filter needle to withdraw the medication after breaking the ampule open
C. Snapping the ampule neck toward the nurse’s body to prevent medication spillage
D. Using the same needle to withdraw the medication and administer the injection to minimize waste
Correct Answer is B. Using a filter needle to withdraw the medication after breaking the ampule open
Rationale:
When opening an ampule, a filter needle must always be used to withdraw medication because small glass particles may contaminate the solution when the ampule neck is broken. This prevents accidental injection of glass fragments.
Option A: Never inject air into an ampule—this causes the medication to bubble and spill.
Option C: The ampule should be broken away from the nurse using a gauze pad, alcohol swab, or ampule guard to avoid injury.
Option D: A new sterile safety needle should always replace the filter needle before injection to prevent tissue irritation and ensure safety.
A nurse is preparing to administer a tuberculin skin test (TST) to a client using the intradermal (ID) route. Which of the following actions by the nurse indicates correct technique?
A. Insert the needle at a 45-degree angle with the bevel down and inject the medication quickly.
B. Use a 1-mL syringe with a 25- to 29-gauge needle and insert at a 5- to 15-degree angle to form a small bleb.
C. Use a 3-mL syringe with a 21-gauge needle and inject at a 90-degree angle into the deltoid muscle.
D. Aspirate for blood return before injecting the medication to prevent intravascular administration.
B is correct: Use a 1-mL syringe with a 25- to 29-gauge needle and insert at a 5- to 15-degree angle to form a small bleb.
Rationale:
B is correct because the intradermal route is used for small volumes (usually ≤0.1 mL), such as tuberculin testing. The injection is made just beneath the epidermis using a tuberculin syringe (1 mL) and a fine 25-, 27-, or 29-gauge needle inserted at a 5–15° angle, creating a small bleb.
A is incorrect because the bevel should be up, and the injection is slow, not quick.
C describes an intramuscular injection, not intradermal.
D is incorrect; aspiration is not done for intradermal injections.
A nurse is preparing to administer a subcutaneous injection of heparin to a client. Which of the following techniques demonstrates correct administration?
A. Insert a 25-gauge, ⅝-inch needle at a 45- to 90-degree angle into the tissue of the upper arm or abdomen.
B. Use a 21-gauge, 1½-inch needle and inject into the deltoid muscle at a 90-degree angle.
C. Inject 2 mL of medication rapidly into the anterior thigh using a tuberculin syringe.
D. Insert the needle at a 15-degree angle into the inner aspect of the forearm until a small bleb appears.
A is correct: Insert a 25-gauge, ⅝-inch needle at a 45- to 90-degree angle into the tissue of the upper arm or abdomen.
Rationale:
A is correct: Subcutaneous injections are given into the tissue below the dermis using a 25-gauge, ⅝-inch or 27-gauge, ⅜- to ½-inch needle. The injection is made at a 45° or 90° angle, depending on the needle length and patient’s body size. Common sites include the upper outer arm, anterior thigh, or abdomen, where there are no major vessels or nerves.
B describes an intramuscular injection, not subcutaneous.
C is incorrect because subcutaneous injections use small volumes (0.05–1 mL) and are injected slowly, not rapidly.
D describes an intradermal injection, which is used for skin testing, not subcutaneous administration.
A nurse is preparing to administer an intramuscular injection of an antibiotic to an adult client. Which of the following actions by the nurse demonstrates correct technique?
A. Use a 25-gauge, ⅝-inch needle inserted at a 45-degree angle into the anterior thigh.
B. Insert a 1- to 3-inch needle at a 90-degree angle into the deltoid, ventrogluteal, or vastus lateralis muscle.
C. Use a 27-gauge, ½-inch needle and insert at a 15-degree angle into the forearm.
D. Choose the abdomen as the preferred injection site to promote slow absorption.
Correct answer is B. Insert a 1- to 3-inch needle at a 90-degree angle into the deltoid, ventrogluteal, or vastus lateralis muscle.
Rationale:
B is correct: Intramuscular (IM) injections deliver medication deep into the muscle for faster absorption than subcutaneous or intradermal routes. Common IM sites include the deltoid, ventrogluteal, vastus lateralis, and rectus femoris. The injection is made at a 90° angle using a 1–3 inch needle, depending on the client’s size and muscle mass.
A describes a subcutaneous injection, not IM.
C describes an intradermal injection, used for skin testing.
D is incorrect because the abdomen is used for subcutaneous injections, not IM, and IM medications typically absorb faster.
A nursing instructor observes a student preparing to administer an intramuscular (IM) injection of a vaccine in the deltoid muscle. The student inserts the needle, pulls back on the plunger to aspirate for blood, and then prepares to inject the medication. Which of the following responses by the instructor is most appropriate?
A. “That’s correct—you should always aspirate before giving any IM injection.”
B. “Aspiration is only required when injecting into the ventrogluteal or deltoid sites.”
C. “You do not need to aspirate for IM injections because it is not evidence-based and may cause unnecessary discomfort.”
D. “You should aspirate for all IM injections except for vaccines.”
Correct answer is C. “You do not need to aspirate for IM injections because it is not evidence-based and may cause unnecessary discomfort.”
Rationale:
C is correct: Current evidence (CDC, 2019) shows that aspiration before IM injection is not supported and is no longer recommended. There is no benefit in preventing intravascular injection for approved IM sites such as the deltoid, ventrogluteal, or vastus lateralis, and aspiration may increase pain and tissue trauma.
A is incorrect — aspiration was part of old practice and is no longer evidence-based.
B is incorrect — aspiration is not required for any recommended IM site.
D is incorrect — aspiration is not recommended for any IM injection, including vaccines. The dorsogluteal site, where aspiration was once advised, is no longer recommended because of proximity to major nerves and blood vessels.
A nurse is preparing to administer an intramuscular injection of 3 mL of medication to an adult patient. Which injection site is most appropriate for this dose?
A. Deltoid muscle
B. Dorsogluteal muscle
C. Subcutaneous tissue of the upper arm
D. Ventrogluteal muscle
Correct Answer is D. Ventrogluteal muscle
Rationale:
The ventrogluteal, vastus lateralis, and rectus femoris sites can safely accommodate up to 3 mL of medication in most adult patients. The deltoid site typically accommodates only 1 mL, and subcutaneous tissue is inappropriate for this volume.
A nurse has just drawn up a medication using a needle and is preparing to administer the injection. Which of the following actions demonstrates safe needle-handling practices to prevent a needle stick injury?
A. Recap the used needle carefully using both hands before disposing of it in the sharps container.
B. Activate the safety device immediately after the injection and dispose of the entire syringe in the sharps container.
C. Use the same needle to draw up the medication and administer the injection to reduce waste.
D. Hold the needle cap in one hand and insert the needle into the cap with the other hand to recap it quickly.
Correct Answer is B. Activate the safety device immediately after the injection and dispose of the entire syringe in the sharp's container.
Rationale:
The Occupational Safety and Health Administration (OSHA) requires use of safety devices to prevent needle stick injuries. After administering an injection, the nurse should immediately activate the needle’s safety feature (e.g., retraction or protective sheath) and dispose of the entire unit in a sharps container.
Option A: Recapping a used needle is never safe and increases the risk of injury.
Option C: A new safety needle should be attached after drawing up medication to avoid depositing medication in surface tissue.
Option D: Using both hands to recap increases risk of accidental puncture. Only a one-hand scoop technique may be used for clean needles, not for used ones.
The nurse is preparing to withdraw medication from a multiple-dose vial. Which nursing action demonstrates correct technique and adherence to infection control principles?
A. Use slight lateral pressure and insert the needle with the bevel up to prevent coring of the rubber stopper.
B. Insert the needle straight through the center of the rubber stopper with the bevel down to prevent coring.
C. Place the vial in the nurse’s pocket during medication preparation to keep it readily accessible.
D. Reuse the same vial for multiple patients as long as the rubber stopper is disinfected between uses.
Correct Answer is A. Use slight lateral pressure and insert the needle with the bevel up to prevent coring of the rubber stopper.
Rationale:
When withdrawing medication from a vial, the nurse should use slight lateral pressure and insert the needle bevel up to prevent coring, which occurs when a piece of the rubber stopper is punched into the vial. Coring can lead to contamination and pose a risk if injected into a patient.
Option B: Inserting the needle straight with the bevel down increases the risk of coring.
Option C: Vials should never be placed in pockets because doing so increases the risk of contamination and temperature exposure.
Option D: Never share vials between patients, even with disinfected stoppers, due to risk of cross-contamination.
The nurse is preparing to administer an antibiotic that comes in powdered form. The vial label states: “Reconstitute with 2 mL of sterile water to yield a concentration of 250 mg/mL.” Which nursing action demonstrates correct technique in reconstituting this medication?
A. Add 2 mL of sterile water, shake the vial vigorously, and draw up the medication immediately.
B. Add any available diluent until the vial is full, then refrigerate before use.
C. Add the specified amount of sterile water, gently roll or swirl the vial to dissolve the powder, and label the vial with the date and time of reconstitution.
D. Add 2 mL of sterile normal saline and use within 24 hours regardless of the manufacturer’s directions.
Correct Answer is C. Add the specified amount of sterile water, gently roll or swirl the vial to dissolve the powder, and label the vial with the date and time of reconstitution.
🧠 Rationale:
Drugs that are unstable in solution are supplied as powders that must be reconstituted with a specific diluent and volume indicated on the vial or package insert. The nurse should:
Use the correct type and amount of diluent (e.g., sterile water or sterile normal saline).
Gently roll or swirl the vial—do not shake vigorously, which may damage the drug.
Label the vial with the date, time, and nurse’s initials after reconstitution.
Follow manufacturer instructions for storage and stability (e.g., refrigeration, expiration time).
Incorrect Options:
A: Shaking can cause foam and damage the medication.
B: Using an unspecified diluent or volume makes the drug concentration inaccurate.
D: Always follow the label’s directions for diluent type and storage; not all medications use normal saline or have a 24-hour expiration.
The nurse is preparing to mix two compatible medications in one syringe. Which action by the nurse demonstrates correct technique?
A. Inject air into both vials, withdraw the longer-acting insulin first, then the shorter-acting insulin.
B. Withdraw both medications without injecting air into either vial to avoid contamination.
C. Inject air into the longer-acting insulin vial first, then into the shorter-acting insulin vial, and withdraw the shorter-acting insulin before the longer-acting insulin.
D. If too much medication is drawn into the syringe, expel the excess back into the vial.
Correct Answer is C. Inject air into the longer-acting insulin vial first, then into the shorter-acting insulin vial, and withdraw the shorter-acting insulin before the longer-acting insulin.
Rationale:
When mixing two compatible medications, such as insulins, the nurse must use a specific sequence to maintain medication integrity and avoid contamination:
Inject air into the longer-acting insulin vial first (without touching the solution).
Inject air into the shorter-acting insulin vial, then withdraw the shorter-acting insulin (e.g., regular insulin).
Withdraw the longer-acting insulin (e.g., NPH) second.
If too much medication is drawn up, discard and start over—never return medication to a vial once mixed.
Incorrect Options:
A: The order of withdrawal is reversed; shorter-acting insulin must be withdrawn first.
B: Air must be injected to prevent creating a vacuum, which makes medication withdrawal difficult.
D: Expelling medication back into the vial after mixing risks contamination and dose inaccuracy.
A hospitalized patient insists on taking her own medication from home instead of the one supplied by the hospital pharmacy. What is the nurse’s best initial action?
A. Allow the patient to take her own medication since it’s the same as the hospital supply.
B. Contact the provider immediately to have the patient’s personal medication discontinued.
C. Lock the patient’s personal medication in the medication room without notifying the provider.
D. Explain the safety risks of taking personal medications without the nurse’s knowledge and determine the patient’s reason for the request.
Correct Answer is D. Explain the safety risks of taking personal medications without the nurse’s knowledge and determine the patient’s reason for the request.
🧠 Rationale:
The nurse should first assess the patient’s reason for wanting to take their own medication and educate the patient on the safety risks associated with doing so—such as medication errors, duplication, or adverse drug interactions.
After discussing and assessing, the nurse should:
Notify the healthcare provider (MD) of the patient’s request.
If approved, ensure the medication is verified, labeled, and stored securely in the patient’s medication supply box.
Verify the MAR for accuracy and update it as needed.
The nurse is preparing to apply a new transdermal pain patch to a patient who reports a pain level of 9/10. Which nursing action demonstrates safe and appropriate technique?
A. Apply the new patch over the old one to maintain continuous medication delivery.
B. Remove the old patch with gloves, clean the site, and apply the new patch to a different hairless area.
C. Place the new patch on an area with scars or rashes to improve absorption.
D. Dispose of the used patch in the regular trash after folding it in half.
Correct Answer is B. Remove the old patch with gloves, clean the site, and apply the new patch to a different hairless area.
Rationale:
Before applying a new transdermal patch, the nurse should remove the previous patch using gloves, clean the old site, and choose a new, clean, dry, hairless area for application. This prevents overdose, skin irritation, and ensures proper absorption.
Option A: Applying a new patch over an old one can cause overdose.
Option C: Avoid applying patches over scars, rashes, or irritated skin because absorption may be altered.
Option D: Used patches should be folded in half (sticky sides together) and disposed of per facility or pharmacy protocol, not in regular trash.
The nurse is preparing to administer a parenteral medication. Which of the following nursing actions demonstrates safe and appropriate practice?
A. Recap the used needle carefully before placing it in the sharps container.
B. Choose the appropriate needle size and syringe based on the medication and injection route.
C. Dispose of used needles and syringes in the regular trash if the sharps container is full.
D. Prepare and administer multiple patients’ injections using the same syringe but new needles each time.
Correct Answer is B. Choose the appropriate needle size and syringe based on the medication and injection route.
Rationale:
Safe medication administration requires using clinical judgment to select the correct needle size and syringe based on the type of injection (IM, subcutaneous, or intradermal). The nurse must also maintain aseptic technique and adhere to the Six Rights of Medication Administration (right patient, drug, dose, route, time, and documentation).
After use, needles and syringes are immediately discarded into an approved sharps container—never recapped, reused, or placed in regular trash.
Incorrect Options:
A: Recapping used needles increases the risk of needle stick injuries.
C: Never dispose of sharps in the trash; contact environmental services if the container is full.
D: Reusing syringes, even with new needles, is unsafe and can cause cross-contamination or infection.
A nurse is preparing to administer a subcutaneous injection. Which of the following sites is most appropriate for a subcutaneous injection?
A. Upper outer arm, abdomen (at least 2 inches from the umbilicus), anterior thigh, or upper back
B. Deltoid muscle of the arm or vastus lateralis
C. Ventrogluteal or dorsogluteal site
D. Inner forearm or bony prominences of the wrist
Correct Answer: A. Upper outer arm, abdomen (at least 2 inches from the umbilicus), anterior thigh, or upper back
Rationale:
Subcutaneous injections are given into the fatty tissue just below the skin, which allows for slower absorption than intramuscular injections.
Common subcutaneous sites include:
Upper outer arm
Abdomen (avoid a 2-inch area around the umbilicus)
Anterior thigh
Upper back or scapular area
Option B and C are intramuscular injection sites, not subcutaneous.
Option D is incorrect because the inner forearm and bony prominences have little subcutaneous tissue, making injections unsafe.
A nurse is preparing to administer subcutaneous insulin to a patient. Which of the following actions demonstrates best practice for high-alert medications?
A. Administer the insulin independently, since the nurse has verified the dose and route.
B. Ask the patient to confirm the dose of insulin before giving it.
C. Have another nurse independently verify the insulin vial and the amount in the syringe before administration.
D. Draw up the insulin and immediately administer it to maintain timely glucose control.
Correct Answer is C. Have another nurse independently verify the insulin vial and the amount in the syringe before administration.
Rationale:
High-alert medications such as insulin, heparin, injectable heart medications, and parenteral chemotherapy drugs have a high risk of causing patient harm if administered incorrectly.
Independent double-checking by another nurse is an evidence-based safety strategy recommended by the Institute for Safe Medication Practices (ISMP) to prevent medication errors.
The second nurse should verify both the medication vial and the dose in the syringe before administration.
Option A: Even experienced nurses must double-check high-alert medications; independent verification is required.
Option B: Patients may not know the correct dose, and this does not replace the double-check procedure.
Option D: Timeliness does not outweigh safety; never skip the double-check for high-alert medications.
A nurse delegates a medication pass to a nursing student for one out of five patients. The nurse then realizes that a medication error occurred during the pass. What is the nurse’s next best action?
A. Call the charge nurse to assist with all five patients while contacting the provider and completing an incident report.
B. Complete an incident report for herself because delegating the medication pass was against standard operating procedures.
C. Determine where the medication error occurred and reassess the affected patient.
D. Reassess all five patients for potential adverse reactions while evaluating where the error occurred.
Correct Answer is D. Reassess all five patients for potential adverse reactions while evaluating where the error occurred.
Rationale:
When a medication error occurs, the nurse’s priority is patient safety:
Immediate assessment: Reassess all patients who received medications to monitor for adverse effects or complications.
Identify the error: Determine which patient(s) were affected, which medication was involved, and the type of error.
Notify the provider: Communicate with the healthcare provider to implement interventions if needed.
Document: Complete an incident report according to facility policy to ensure proper follow-up and quality improvement.
Option A: While notifying the provider and documenting is important, patient assessment takes priority.
Option B: The nurse is not automatically at fault; the priority is patient safety, not self-reporting.
Option C: Only reassessing the patient where the error occurred is incomplete; other patients could also be affected.
Scenario:
A nurse is preparing to administer 2 mL of iron dextran intramuscularly to a patient. The patient reports mild anxiety about pain and bruising from previous injections.
Question:
Which of the following actions demonstrates correct and evidence-based practice for administering this medication?
A. Use the Z-track technique in a large muscle, retract the skin laterally, inject the medication slowly at a 90-degree angle, wait 10 seconds, and release the skin as the needle is withdrawn.
B. Administer the injection into the deltoid using a 1-inch needle at a 45-degree angle and massage the site afterward to reduce pain.
C. Inject the medication quickly into any accessible muscle and apply a warm compress to the site afterward.
D. Administer the medication using a subcutaneous injection in the abdomen to prevent bruising in the muscle.
Correct Answer is A. Use the Z-track technique in a large muscle, retract the skin laterally, inject the medication slowly at a 90-degree angle, wait 10 seconds, and release the skin as the needle is withdrawn.
Rationale:
The Z-track technique is recommended for medications like iron dextran, hydroxyzine, and some antipsychotics to prevent medication from leaking into subcutaneous tissue, which can cause staining, bruising, and pain.
Key steps include:
Selecting a large muscle (e.g., ventrogluteal).
Retracting the skin laterally to create a zig-zag needle track.
Injecting slowly at 90 degrees and waiting 10 seconds before needle withdrawal.
Releasing the skin after needle removal and not massaging the site.
Option B: 1-inch needle and 45-degree angle are inappropriate for deep IM injections; massaging increases tissue irritation.
Option C: Fast injection and warm compress do not prevent tissue staining or bruising.
Option D: Subcutaneous administration is not appropriate for iron dextran and other IM medications that require Z-track technique.
Scenario:
A 35-year-old patient is admitted for an intramuscular injection of an antibiotic. The nurse reviews the patient’s chart and notes no allergies. The patient has well-developed musculature in the arms and thighs. The nurse prepares to administer the injection.
Question:
Which site is most appropriate for this patient’s IM injection, and why should other sites be avoided?
A. Dorsogluteal site because it allows for a deep injection and rapid absorption.
B. Mid-deltoid site, three finger-widths below the acromion process, because it is easily accessible and avoids major nerves and blood vessels.
C. Vastus lateralis site, because it is always safer than the deltoid for adults.
D. Ventrogluteal site, because the dorsogluteal site has fewer risks.
Correct Answer is B. Mid-deltoid site, three finger-widths below the acromion process, because it is easily accessible and avoids major nerves and blood vessels.
Rationale:
The mid-deltoid site is preferred for adults with adequate muscle mass because it is accessible and avoids critical structures like the sciatic nerve and major blood vessels.
Dorsogluteal site (Option A) is no longer recommended due to risk of sciatic nerve injury.
Vastus lateralis (Option C) is an acceptable alternative, but the deltoid is more convenient for adults with well-developed arm muscles; it is not always safer than the deltoid.
Ventrogluteal site (Option D) is a safe alternative, but in adults with accessible deltoid muscle, the deltoid is preferred for small-volume injections and patient comfort.
A nurse is preparing to administer a subcutaneous injection of heparin. Which of the following actions demonstrates safe and appropriate technique?
A. Administer the injection in the upper arm and gently massage the site afterward to improve absorption.
B. Administer the injection into the abdomen, rotate sites, and avoid massaging the area after injection.
C. Administer the injection into the thigh or arm and have another nurse verify the dosage only if it is the first time giving heparin.
D. Administer the injection in the same abdominal site every time to ensure consistent absorption.
Correct Answer is B. Administer the injection into the abdomen, rotate sites, and avoid massaging the area after injection.
Rationale:
Heparin is an anticoagulant, so special precautions are necessary to reduce the risk of bleeding, bruising, and ecchymosis.
The abdomen is preferred for subcutaneous injections because it has minimal muscular activity, reducing variability in absorption.
Sites should be rotated within the abdominal area to avoid repeated trauma to the same tissue.
Do not massage the injection site; massaging can cause tissue trauma and bleeding.
A second nurse should verify the syringe and dose every time heparin is prepared due to the risk of dosing errors.
Incorrect Options:
A: Upper arm is less preferred, and massaging increases risk of bleeding.
C: Arms and thighs are less ideal for heparin, and double-checking is required for all doses, not just the first.
D: Using the same site repeatedly can increase bruising and tissue damage.
A nurse hands her prepared medications to a co-worker and leaves the unit to eat lunch. What should the co-worker do next?
A. Administer the medications as handed to her, since the other nurse prepared them.
B. Take the medications, give them only to the patients she knows, and document administration.
C. Refuse to administer the medications and remind the nurse that it is unsafe and violates policy.
D. Store the medications in the medication cart until the original nurse returns.
Correct Answer is C. Refuse to administer the medications and remind the nurse that it is unsafe and violates policy.
Rationale:
Delegating medication administration in this manner is unsafe and a violation of policy. Nurses must personally verify the Six Rights of Medication Administration (right patient, drug, dose, route, time, and documentation) before giving any medication.
Administering medications prepared by another nurse without verification increases the risk of medication errors and patient harm.
The coworker should refuse to administer, educate the other nurse on proper procedure, and report unsafe practice to the charge nurse or supervisor if needed.
Options A, B, and D are unsafe because they bypass the required verification steps and violate professional and facility standards.
Scenario:
A patient is receiving a parenteral antibiotic for the first time. The patient has no known drug allergies. Thirty minutes after the injection, the patient reports shortness of breath and develops wheezing, generalized hives, and swelling of the lips.
Question:
What is the nurse’s priority action?
A. Document the reaction in the patient’s chart and notify the provider at the end of the shift.
B. Give an oral antihistamine and continue to monitor the patient for 30 minutes.
C. Immediately stop the infusion, call for help, assess airway and breathing, administer oxygen, and be prepared to give emergency medications.
D. Encourage the patient to take deep breaths and elevate the legs to improve circulation.
Correct Answer is C. Immediately stop the infusion, call for help, assess airway and breathing, administer oxygen, and be prepared to give emergency medications.
Rationale:
The patient is showing classic signs of anaphylactic shock: wheezing, urticaria, facial edema, and shortness of breath.
Anaphylaxis is a medical emergency that can progress to circulatory collapse and death within minutes.
Priority actions include:
Stop the medication immediately.
Call for emergency help and alert the provider.
Assess airway, breathing, and circulation (ABCs).
Administer oxygen and be ready to give epinephrine or other emergency drugs per protocol.
Option A: Delaying action is unsafe; immediate intervention is critical.
Option B: Oral antihistamines are insufficient for severe reactions.
Option D: Deep breaths and leg elevation do not address airway obstruction or circulatory collapse.