A nurse is administering an IM injection using a passive needle-safety device. After injection, which of the following actions should the nurse take?

Activate the device immediately after injection.

Remove the safety device before disposal.

Make sure the needle retracts into the barrel of the syringe.

Pull the plastic sheath over the needle.

Answer and Explanation

The Correct Answer is A

A.   After administering the injection, activating the passive needle-safety device involves a mechanism where the safety feature automatically engages. This can include a shield that covers the needle or a mechanism that retracts the needle into the syringe or device. It's crucial to activate this immediately after injection to prevent accidental needlestick injuries.
B.   The safety device, once activated, should remain in place and intact on the needle until it is safely disposed of in an appropriate sharps container. Removing the safety device before disposal would expose healthcare workers to potential needlestick injuries.
C.   There is no need to make sure the needle retracts into the barrel of the syringe, as the safety device is designed to cover the needle after use.
D.   While some devices have a plastic sheath or shield that covers the needle before and after use, the primary action for a passive device is to activate the safety feature that automatically covers or retracts the needle post-injection. Pulling a sheath over the needle manually is more typical for active safety devices or conventional needles with manual sheath covers.

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Correct Answer is C

Explanation

A. Place the client in a high Fowler's position:High Fowler’s would increase intra-abdominal pressure and strain sutures. For peritonitis recovery, semi-Fowler’s is preferred-promotes drainage of peritoneal fluid into the pelvis, preventing spread to diaphragm and lungs.

B. Ambulate the client twice daily:Too early after peritonitis lavage. Initially, the client is very weak, at risk for sepsis/shock. Early ambulation is not a priority here.

C. Mark abdominal girth once daily:Abdominal girth measurement is important to monitor for distention, fluid accumulation, or bleeding. Marking ensures accuracy in repeated measurements. This is a key intervention in monitoring postop peritonitis.

D. Irrigate the nasogastric tube with tap water:Never irrigate with tap water (risk of electrolyte imbalance, infection). Only sterile normal saline or as prescribed is used.

A. Excessive pulmonary secretions B. Cracks in oral mucous membranes C. Tachycardia D. Poor skin turgor

Correct Answer is B

Explanation

A. Excessive pulmonary secretions can be a sign of airway irritation or infection rather than a direct adverse effect of oxygen therapy. It may warrant further assessment and intervention, but it is not typically attributed to oxygen therapy itself.
B. Dryness and cracking of oral mucous membranes can occur as a result of oxygen therapy. Oxygen delivered at higher concentrations or for prolonged periods can dry out mucous membranes, leading to discomfort and potential cracking.
C. Tachycardia (an elevated heart rate) can occur as a compensatory response to hypoxia or increased metabolic demands rather than as a direct adverse effect of oxygen therapy. However, if oxygen therapy leads to an overcorrection of hypoxemia, it could potentially contribute to changes in heart rate.
D. Poor skin turgor is typically a sign of dehydration or fluid imbalance, not directly related to oxygen therapy. It may be important to assess fluid status in clients receiving oxygen therapy, but poor skin turgor itself is not an adverse effect of oxygen administration.

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A nurse is administering an IM injection using a passive needle-safety device. After injection, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed- suction drains in place. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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