Nokea
The nurse is administering an intramuscular (IM) injection to a client. When the nurse aspirates, there is a blood return. What is the most appropriate action for the nurse to take?
- A. Continue to administer the medication
- B. Withdraw the needle and administer in another site
- C. Withdraw the needle, discard the medication, and start over
- D. Change the needle before administering the medication in another site
Correct Answer: C
Rationale: The nurse should not inject medication that has blood in it. Blood may interact with the medication and cause an adverse response.
You may also like to solve these questions
A nurse is caring for a client who is receiving methyldopa hydrochloride (Aldomet) intravenously. Which of the following assessment findings would indicate to the nurse that the client may be having an adverse reaction to the medication?
- A. Headache
- B. Mood changes
- C. Hyperkalemia
- D. Palpitations
Correct Answer: B
Rationale: Mood changes. The nurse should assess the client for alterations in mental status such as mood changes. These symptoms should be reported promptly.
The client received Narcan, a narcotic antagonist, following a colonoscopy. Which action by the nurse has the highest priority?
- A. Document the occurrence in the nurse's notes.
- B. Prepare to administer narcotic medication IV.
- C. Administer oxygen via nasal cannula.
- D. Assess the client every 15 to 30 minutes.
Correct Answer: D
Rationale: Narcan reverses opioids but has a short half-life; frequent assessment (15–30 min) monitors for re-sedation or respiratory depression, the priority.
The nurse is monitoring a client receiving a thrombolytic agent, alteplase (Activase tissue plasminogen activator), for treatment of a myocardial infarction. What outcome indicates the client is receiving adequate therapy within the first hours of treatment?
- A. Absence of a dysrhythmia (or arrhythmia)
- B. Blood pressure reduction
- C. Cardiac enzymes are within normal limits
- D. Return of ST segment to baseline on ECG
Correct Answer: D
Rationale: Return of ST segment to baseline on ECG. Improved perfusion should result from this medication, along with the reduction of ST segment elevation.
The client is receiving atropine, an anticholinergic, to minimize the side effects of routine medications. Which intervention will help the client tolerate this medication?
- A. Teach the client about orthostatic hypotension.
- B. Instruct the client to eat a low-residue diet.
- C. Encourage the client to chew sugarless gum.
- D. Discuss the importance of daily isometric exercises.
Correct Answer: C
Rationale: Atropine causes dry mouth; sugarless gum stimulates saliva, improving tolerance. Hypotension, diet, or exercises are unrelated.
The nurse is instructing a client with moderate persistent asthma on the proper method for using MDIs (multi-dose inhalers). Which medication should be administered first?
- A. Steroid
- B. Anticholinergic
- C. Mast cell stabilizer
- D. Beta agonist
Correct Answer: D
Rationale: Beta agonist. The beta-agonist drugs help to relieve bronchospasm by relaxing the smooth muscle of the airway. These drugs should be taken first so that other medications can reach the lungs.